University of Massachusetts Amherst

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Doctor of Nursing Practice (DNP) Projects College of Nursing

2017

The Negative Impact of Excessive Screen Time on

Language Development in Children Under
6-Years-Old: An Integrative Review with Screen
Time Reduction Toolkit and Presentation for
Outpatient Pediatric and Family Health Providers
Cristina Kuta

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Integrative Review with Screen Time Reduction Toolkit and Presentation for Outpatient Pediatric and Family Health Providers"
(2017). Doctor of Nursing Practice (DNP) Projects. 91.
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Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 1

The Negative Impact of Excessive Screen Time on Language Development in Children Under

6-Years-Old: An Integrative Review with Screen Time Reduction Toolkit and Presentation for

Outpatient Pediatric and Family Health Providers

Cristina E. Kuta

University of Massachusettes, Amherst

College of Nursing

DNP Project Chair: Dr. Jean DeMartinis PhD, FNP-BC

Date of Submission: May 4, 2017

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 2

Table of Contents

Abstract................................................................................................................................ 4

Introduction and Background .............................................................................................. 6

Problem Statement............................................................................................................. 10

Integrative Review of the Literature.................................................................................. 10

Methods ....................................................................................................................... 10

Search Strategy ...................................................................................................... 10

Inclusion and Exclusion Criteria ........................................................................... 11

Assessment of Methodological Quality................................................................. 11

Results ......................................................................................................................... 11

Study Characteristics ............................................................................................. 11

Intervention Components and Results ................................................................... 12

Discussion.................................................................................................................... 16

Evidence Based Practice: Verification of Chosen Option ........................................... 19

Theoretical Framework ..................................................................................................... 19

Goals, Objectives and Expected Outcomes ....................................................................... 21

Project Design and Methods .............................................................................................. 22

Population, Settings and Resources ............................................................................. 23

Facilitators and Barriers .............................................................................................. 24

Toolkit and Presentation Implementation Plan Summary ................................................. 25

Toolkit ......................................................................................................................... 25

Pre-Toolkit Preparation ......................................................................................... 25

Toolkit Development ............................................................................................. 25

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 3

Presentation ................................................................................................................. 27

Evaluation .................................................................................................................... 27

Pre-Presentation Survey ........................................................................................ 27

Post-Presentation Evaluation ................................................................................. 28

Data Analysis............................................................................................................... 28

Results ......................................................................................................................... 29

Pre-Presentation Survey ........................................................................................ 29

Post-Presentation Evaluation ................................................................................. 31

Outcomes ........................................................................................................................... 31

Discussion.......................................................................................................................... 33

Influence on Knowledge and Beliefs .................................................................... 33

Use of the Integrative Review and Screen Time Reduction Toolkit ..................... 35

Limitations ............................................................................................................. 36

Future Recommendations ...................................................................................... 37

Ethics and Human Subjects Protection.............................................................................. 37

Conclusion ......................................................................................................................... 38

References ......................................................................................................................... 39

Appendix A ....................................................................................................................... 43

Appendix B ........................................................................................................................ 44

Appendix C ...................................................................................................................... 146

Appendix D ..................................................................................................................... 148

Appendix E ...................................................................................................................... 150

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 4

Abstract

Background. Increased amounts of recreational screen time, defined as time watching television

and DVDs, playing videogames, and using computers, tablets, and cellular phones without

academic purpose, and the lack of effective media use assessment and patient education being

done by primary care providers is associated with increased risk of language developmental

delays for young children under 6-years-old.

Purpose. The purpose of this integrative review is to develop a toolkit that provides education

for providers and families on the adverse effects of excessive screen time on language

development in children younger than 6-years-old and evidence-based screen time reduction

strategies that can be implemented in outpatient primary care clinics at all wellness visits.

Toolkit and Presentation. An integrative review was conducted to describe the effects of

excessive screen time on language development for children under age 6 and analyze

interventions to decrease screen time. From these results, the Screen Time Reduction Toolkit was

created. The toolkit includes the 2-Question Assessment for Screen Time (2-QAST), screen time

reduction algorithm, provider and patient education on health risks associated with excessive

screen time, screen time recommendations published by the American Academy of Pediatrics

(AAP), and evidence-based screen time reduction strategies, provider resources, and patient

education handouts. The integrative review findings and toolkit were presented to a group of

local pediatric providers, nurses, and medical technicians for education and implementation.

Outcomes/Discussion. The pre-presentation survey was created after the Health Belief Model

(HBM), which served as the framework for this educational intervention. Staff members had

high perceived seriousness (83%), perceived susceptibility (83%), and perceived benefit (100%),

demonstrating that staff members’ attitudes and beliefs about screen time for young children
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 5

were in agreement with the principles of this project. Barriers identified included lack of

knowledge about health risks from excessive screen time, potential for parental resistance to

screen time reduction advice, and time constraints during wellness visits. Regarding cues to

action, staff members requested visual aids, handouts, and more education about screen time.

The toolkit and patient education resources reduce barriers and address cues to action identified

by the staff members. The post-presentation evaluation revealed that 100% of staff members

found the toolkit presentation informative and said it increased their knowledge and

understanding of the topic.

Conclusion. The toolkit provides the education that providers need to be knowledgeable as well

as confident in their ability to discuss screen time with families. Being consistent about

providing a few minutes of screen time education at every wellness visit from 2-months-old to 5-

years-old sets a solid foundation for parents and children to create healthier screen time habits at

home.

Keywords: Screen time, television, media use, children, language delay

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 6

The Negative Impact of Excessive Screen Time on Language Development in Children Under

6-Years-Old: An Integrative Review with Screen Time Reduction Toolkit and Presentation for

Outpatient Pediatric and Family Health Providers

Introduction and Background

Language development and vocabulary growth in young children are directly related to

the amount of time parents spend speaking to them. Kuhl (2004) reported that in studies

examining speech-perception learning and speech-production learning, human-human

interactions had a strong influence on a child’s language development. She also reported that

infants learned best from live sessions versus televised ones, and social feedback was an

important predictor for the quantity and quality of infant vocalizations. Therefore, heavy

television use or excessive screen time can interfere with a child's language development because

parents spend less time interacting with and talking to their child. Furthermore, receptive

language delays by age 5 are a significant risk factor for social and emotional problems in

adulthood (Schoon, Parsons, Rush, & Law, 2010).

Results from several studies support this association between excessive screen time in

children under 6-years-old and language delays (Chonchaiya & Pruksananonda, 2008; Duch et

al., 2013; Lin et al., 2015). Lin, Cherng, Chen, Chen, and Yang (2015) conducted a quasi-

experimental study and determined that exposure to television was correlated with an increased

risk for language developmental delays in young children ages 15- to 35-months-old. The

exposure group consisted of 75 children who watched an average of 137.2 min/day. The 75

children in the control group watched an average of 16.3 min/day. The exposure group’s risk of

delayed language development was 3.3 times higher than that of the control group. Duch et al.

(2013) found that Hispanic infants and toddlers who watched excessive television, defined as
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 7

2 hr/day or more, had 5.5 times the risk of having lower scores on the Communication section of

the Ages and Stages Questionnaire (ASQ-3) after 1 year compared to those children who

watched less than 2 hr/day. Chonchaiya and Pruksananonda (2008) also conducted a study with a

sample of 56 children with language delays and 110 children with normal language development,

ages 15- to 48-months-old. They asserted that children who started watching television before 12

months of age and watched more than 2 hr/day were six times more likely to develop a language

delay. Although studies on the relationship between screen time and language development are

few and mostly limited to observational or quasi-experimental methods, findings have remained

consistent that increased screen time is associated with an increased risk for language

developmental delays.

Researchers have also investigated how screen time interferes with language

development by examining the interactions between young children and their caregivers

(Chonchaiya & Pruksananonda, 2008; Christakis et al., 2009; Tanimura, Okuma, & Kyoshima,

2007). Christakis et al. (2009) explored verbal exchanges between a parent and child while

watching television. They conducted an observational study to determine the relationship

between the amount of time watching television and the number of parent-child interactions in a

group of 326 children ages 2 to 36 months. For every 1 hr of television watched, the children

were exposed to 500 to 1000 fewer words. The authors also ascertained that significant

reductions for child vocalizations, vocalization duration, and conversational turns were

associated with more time spent watching television. These decreased experiences for parent-

child interactive language learning may impact normal language development. Chonchaiya and

Pruksananonda (2008) established an association between the amounts of time caregivers

interacted and conversed with their children in a day and risk for developing language delays.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 8

The children with language delays spent an average of 7 hr/day with their caregivers in which

3.6 of those hours, on average, were spent in conversation. The children in the control group with

normal language development spent an average of 9.3 hr/day with their caregivers in which 5.8

of those hours, on average, were spent in conversation. Furthermore, Chonchaiya and

Pruksananonda (2008) determined that children who watched television alone were 8.5 times

more likely to develop a language delay. Similarly, Tanimura, Okuma, and Kyoshima (2007)

observed that when the television is on, parents converse and interact less with their children. In

an observational study performed in Japan, parents frequently spoke in shorter, one-word

sentences and spoke less words overall to their children when the television was on. Taken

together, results from these studies support the premise that television viewing disrupts

caregiver-child verbal interactions, which results in less words being spoken to the child and less

opportunities for modeling two-way conversation and conveying thoughts in sentences rather

than single words.

The American Academy of Pediatrics (AAP) advisory board recognizes the health

implications of too much screen time. In addition to language delays, children are at increased

risk for obesity, violence and aggression, loss of social skills, attention problems, anxiety and

depression, sleep deprivation, vision problems, migraine headaches, repetitive motion syndrome

and arthritis (American Academy of Pediatrics [AAP], 2016). In January 2017, the AAP

advisory board ratified an online Media and Children Communication Toolkit, which encourages

families to create a media use plan to gain awareness of media use habits and adopt methods to

decrease use. In their most recent 2016 policy statement, the AAP advisory board advocated for

no screen time in children under the age of 18-24 months other than video-chatting and to limit

screen time to less than 1 hr/day of high-quality programming and apps for children ages 2-5
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 9

because of the harmful impact it might have on the developing brain. They also recommended

caregivers co-view and co-use media, not allow screen time during meals or for 1 hour before

bedtime, and remove televisions and other media devices from children’s bedrooms. Still,

according to parent surveys, 90% of children younger than 2-years-old are exposed to 1 to 2

hr/day of television with 14% of them watching greater than 2 hr/day of television (AAP, 2011).

Thirty-eight percent of infants use mobile devices like smartphones (Rideout, 2013). The typical

American child before age 5 watches 4.5 hr/day of television (Christakis, 2011).

Many caregivers believe that screen media can have a positive impact on their child’s

cognitive development because many programs and products advertise this as a benefit (AAP,

2011; Beck et al., 2015; Vandewater et al., 2005). Caregivers who believe a television program

or video is educational and important to healthy development are twice as likely to have the

television on for extended periods of time (Vandewater et al., 2005). An interview with a group

of Hispanic families found limited knowledge among caregivers about the potential risks of too

much screen time, but the caregivers also reported they would reduce their children’s screen time

if they were better educated about this issue (Beck et al., 2015). Improved education and

awareness about the potential for language delays in young children due to excessive screen time

can empower families to reduce screen time in their homes.

The primary care setting offers excellent opportunities to promote screen reduction

education to young children and their families. From birth to age 5, children will see their

provider a minimum of 12 times for routine wellness visits. Despite this opportunity only 16% of

pediatricians in the United States ask patients and their families about their media use, and this

statistic has not changed in the last 20 years despite the production of new devices providing
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 10

more opportunities for screen time, including tablets, portable DVD players, and smartphones

(Shifrin et al., 2015).

Problem Statement

Increased amounts of recreational screen time, defined as time watching television

and DVDs, playing videogames, and using computers, tablets, and cellular phones without

academic purpose, and the lack of effective media use assessment and patient education being

done by primary care providers is associated with increased risk of language developmental

delays for young children under 6-years-old. This is a significant issue because language

development is biologically correlated to age, and these early years are crucial for language

acquisition, especially phonetics and syntax.

Integrative Review of the Literature

Methods

Search strategy. A three-step search strategy was utilized in this review to find

published studies. An initial limited search of Medical Literature Anayslis and Retrieval System

Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL)

was undertaken followed by an analysis of the text words contained in the title and abstract, and

of the index terms used to describe the article. A second search using all identified keywords and

index terms was then undertaken across CINAHL, PubMed/MEDLINE, and PubMed Central.

The following keywords and combinations were searched in CINAHL: young children,

television, television viewing, television viewing reduction, decreasing television viewing, media

use, media use reduction, decreasing media use, screen time, screen time reduction, decreasing

screen time, language, language development, and language delays. The following Medical

Subject Headings (MeSH) and combinations were searched in PubMed/MEDLINE and PubMed
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 11

Central: television, language development disorders, child—preschool, and infant. Thirdly, the

reference list of all identified reports and articles were searched for additional studies. Studies

published in English between 2004 and 2016 were considered for inclusion in this review.

Inclusion and exclusion criteria. The following inclusion criteria were applied: (1)

studies involving children under age 6 from any country, (2) studies that evaluated the effect of

screen time, television viewing, or media use on language development, (3) studies that

implemented interventions in the primary care setting to reduce screen time, television viewing,

or media use. This review included studies with the following outcomes: decreased risk of

language developmental delays and decreased screen time, television viewing, or media use.

This review examined both experimental and epidemiological study designs during the search

process including randomized controlled trials (RCTs), non-RCTs, quasi-experimental studies,

before and after studies, prospective and retrospective cohort studies, case control studies and

analytical cross sectional studies for inclusion. Descriptive epidemiological study designs

including case series, individual case reports and descriptive cross sectional studies were also

reviewed and considered for inclusion.

Assessment of methodological quality. Papers selected for retrieval were evaluated

using the Evidence Appraisal Tools from the John Hopkins Nursing Evidence-Based Practice

Model (Dearholt & Dang, 2012).

Results

Study characteristics. A search of CINAHL, MEDLINE, PubMed and PubMed Central

resulted in 771 studies. From these results, 120 articles were extracted with 55 of them being

duplicates. The titles and abstracts of the remaining 65 studies were reviewed using the inclusion

criteria and excluded if the criteria was not met. Fifty-five studies were excluded due to
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 12

children’s ages being greater than 5-years-old, non-primary care based setting used and

intervention not practical for primary care. At the conclusion of the search, 10 studies met the

criteria and were included in this review. Two of the studies were Level IA systematic

reviews/meta-analyses (Downing, et al., 2016; Wahi et al., 2011). Five of the studies involved

primary care or clinic-based interventions consisting of four Level IA RCTs (Birken et al., 2012;

Campbell et al., 2013; Taveras et al., 2011b; Yilmaz et al., 2014) and one Level IIC pilot non-

RCT (Taveras et al., 2011a). The remaining studies included one school-based Level I RCT

(Dennison et al., 2004) and two family-centered, community-based pilot RCTs (Hinkley et al.,

2015; Zimmerman et al., 2012) involving interventions that could be practically translated to the

primary-care setting. All of these studies examined screen time, television viewing, or media use

reduction interventions. However, no experimental studies were found that discussed an

associated risk reduction in language development with screen time reduction; rather, most of

these studies examined obesity-related associations such as Body Mass Index (BMI), sedentary

activities, and unhealthy foods.

Intervention components and results. Wahi et al. (2011) performed one of the first

systematic reviews and meta-analyses to determine how effective interventions were at

decreasing screen time in children of all ages. However, none of the included 13 studies were

performed in the primary care setting. Still, those that involved children ages 2 to 6 were the only

studies to show a significant reduction in screen time for the intervention group. They concluded

that multiple sessions over a prolonged period of time that focus on key age groups might create

a sustainable behavioral change.

Along those lines, Campbell et al. (2013) postulated that parents may be more receptive

and have a greater desire to learn about improving their child’s health when their children are
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 13

quite young, which might explain screen time reduction success in children younger than 6-

years-old. They conducted a successful quarterly clinic-based intervention to first time parent

groups with children ages 4- to 18-months-old. Classes were dietician-delivered 2-hour sessions

on infant feeding, diet, physical activity, and television viewing using DVDs, in-class written

materials, and take-home newsletters. The 271 children in the intervention group from a sample

of 542 children decreased their television viewing time by 25% compared to the control group.

Dennison, Russo, Burdick, and Jenkins (2004) were the first to implement a school-based

intervention to decrease screen time in preschoolers. Ninety children ages 2.6 to 5.5 years old

participated in the intervention group and decreased their television viewing by 3.1 hr/week. The

percentage of children who watched television for more than 2 hr/week also decreased from 33%

to 18%. Through seven 20-min weekly sessions, they urged children to read books daily and

encouraged parents to remove televisions and Internet-ready devices from children’s bedrooms

and to have family meal times without television. Children brainstormed lists of alternative

activities and were encouraged to act as advocates for reducing screen time. Various educational

materials were sent home describing strategies to limit media use. Finally, children were

challenged to be television-free for 7 to 10 days. This study was included in this review because

the interventions could be translated to the primary care setting.

To illustrate this, Yilmaz, Caylan, and Karacan (2014) intervened at health maintenance

visits in the primary care setting and incorporated these same interventions in the forms of

printed materials and CDs, counseling calls, picture books depicting screen-free homes, and

handouts with success stories. This screen time education was provided to patients and their

families every 2 weeks for 8 weeks. They sampled 363 children, ages 2- to 6-years-old, and their
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 14

families. The 187 children in the intervention group had an overall decrease in television viewing

from 86 min/day to 21 min/day after 9 months.

Taveras et al. (2011b) were also successful in decreasing screen time by intervening in

the primary care setting. Like Yilmaz et al. (2014), the intervention was conducted over several

sessions: four 25-min in-person sessions and two 15-min phone calls completed over 1 year.

Motivational interviewing was the primary technique used in addition to printed educational

information. Parents were encouraged to choose two out of six possible intervention activities

with screen time reduction being one of them. They sampled 475 children ages 2- to 6-years-old

and decreased total television viewing time by an average of 36 min/day among the 271 children

in the intervention group. However, some of the children decreased their screen time by as much

as 58 min/day if their parents specifically chose that intervention activity.

Taveras et al. (2011a) also conducted a primary care based pilot RCT targeting mother-

infant pairs during each well child visit from birth to age 6 months. This study successfully used

clinician-directed motivational interviewing, specifically family-centered collaborative

negotiation, to discuss television viewing time. They also provided parents with comprehensive

educational materials. Because this was a pilot study, the sample size was small, but the results

are promising. They sampled 84 infants up to 6-months-old, and television viewing decreased

from 1.5 hr/day to 1.2 hr/day for the 60 infants in the intervention group.

One primary care based RCT (Birken et al., 2012) did not show any change in screen

time post-intervention. Unlike the other three primary care based studies included in this review,

Birken et al. (2012) used a one-time intervention. They provided a single 10-min educational

discussion about screen time reduction at the 3-year well child visit to an intervention group of

81 children. No significant change in screen time habits was sustained when they followed up 1
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 15

year later. Birken et al. (2012) concluded that short interventions might not be useful for

preschool-aged children and that repeated reinforcement may be needed.

Downing, Hnatiuk, Hinkley, Salmon, and Hesketh (2016) performed the most recently

published systematic review and meta-analysis of RCTs using interventions to improve

sedentary behaviors among 0-5-year-olds. Television viewing time was listed as one of these

sedentary behaviors. They concluded that screen time reduction interventions proved more

successful when they were long-term, occurring for more than 6 months, and required strong

parental involvement. Because there were few primary care based studies, they could not draw

definitive conclusions about the success of interventions conducted in that setting. However, they

did highlight the positive effect of motivational interviewing on changing behaviors.

The following two studies (Hinkley et al., 2015; Zimmerman et al., 2012), although

community-based, were included in this review because improving education about screen time

was the primary intervention. Education can easily be incorporated into the primary care setting

and is the foundation for the interventions in all of the studies previously discussed.

The small sample size of only 22 2-3-year-old children was the major drawback for the

community-based, family-centered pilot RCT conducted by Hinkley et al. (2015). Their primary

intervention was using educational sessions to reduce daily amount of electronic media use,

which included increasing knowledge about current recommendations, potential adverse

outcomes of use, and strategies to reduce electronic media use. These 1-hr long educational

sessions were held weekly for 6 weeks. They were able to decrease daily electronic media use by

33% or 39 min/day.

Likewise, Zimmerman et al. (2012) conducted a community-based pilot RCT for children

ages 2.5 to 4.5-years-old. Again, the major drawback of the study was its small sample size: 67
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 16

participants with 34 in the intervention group. Over the course of 4 months, children in the

intervention group and their parents received written educational materials encouraging parents

to reduce their child’s media viewing to less than 1 hr/day. The intervention group reduced their

total television viewing time by 39 min/day or 30% compared to the control group. Zimmerman

et al. (2012) concluded that clearly communicating to parents about the potential health risks of

excessive media use and providing them screen time reduction strategies and alternative

activities can make screen time reduction possible.

In summary, all of these research teams used common screen time reduction topics as

part of their educational sessions: screen time recommendations based on age, health risks of

excessive screen time, setting rules for use such as no screens during family meal times or 1-hr

before bedtime, co-viewing and co-using media, displacing screen time with other activities such

as reading, removing televisions and other media devices from children’s bedrooms, and

advocating for educational media and a screen-free week.

Discussion

The technologizing of childhood is an emerging topic of interest (Christakis, 2015).

Therefore, few studies exist for screen time reduction interventions in the primary care setting

specific for children younger than 6-years-old, but the results from the studies examined in this

integrative review are promising. This integrative review included two systematic reviews/meta-

analyses (Downing et al., 2016; Wahi et al., 2011), five RCTs (Birken et al., 2012; Campbell et

al., 2013; Dennison et al., 2004; Taveras et al., 2011b; Yilmaz et al., 2014), two pilot RCTs

(Hinkley et al., 2015; Zimmerman et al., 2012), and one pilot non-RCT (Taveras et al., 2011a).

Table 1 lists the seven primary experimental studies included in this review (Campbell et al.,

2013; Dennison et al., 2004; Hinkley et al., 2015; Taveras et al., 2011a; Taveras et al., 2011b;
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 17

Yilmaz et al., 2014; Zimmerman et al., 2012) and outlines the study type, setting, intervention

time, and resulting screen time reduction. The RCT results by Birken et al. (2012) were

determined to be an outlier and were not included in the table or any of the calculations

discussed below; they implemented a single 10-min intervention which resulted in no significant

reduction in screen time when surveyed 1 year later. The table also does not list the two

systematic reviews/meta-analyses (Downing, et al., 2016; Wahi et al., 2011).

Table 1

Screen Time Reduction Based on Study Type, Setting, and Intervention Time

Intervention Screen Time

Author/Year Study Type Setting
Time (wks) Reduction (min/day)
Hinkley (2015) Pilot RCT Community 5 39
Yilmaz (2014) RCT Primary Care 8 65
Campbell (2013) RCT Primary Care 65 15
Zimmerman (2012) Pilot RCT Community 17 39
Taveras (2011a) Pilot non-RCT Primary Care 26 20
Taveras (2011b) RCT Primary Care 52 36 (58)
Dennison (2004) RCT School 6 27

In their recent systematic review/meta-analysis specifically looking at screen time

reduction for children under 6-years-old in all types of setting, Downing et al. (2016) concluded

that screen time reduction interventions lasting longer than 6 months were more effective. The

average length of intervention of the seven successful experimental studies included in this

integrative review was 32 weeks or 7.4 months (Campbell et al., 2013; Dennison et al., 2004;

Hinkley et al., 2015; Taveras et al., 2011a; Taveras et al., 2011b; Yilmaz et al., 2014;

Zimmerman et al., 2012). Three of the studies lasted between 5 and 8 weeks (Dennison et al.,

2004; Hinkley et al., 2015; Yilmaz et al., 2014). The other four studies lasted from 17 to 65

weeks (Campbell et al., 2013; Taveras et al., 2011a; Taveras et al., 2011b; Zimmerman et al.,

2012). Two of the studies, one lasting 27 weeks (Taveras et al., 2011a) and the other lasting 65
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 18

weeks (Campbell et al., 2013), had interventions that were successfully done at every well child

visit.

Downing et al. (2016) also found an average screen time reduction of 17 min/day in their

systematic review/meta-analysis. The average reduction in screen time from the seven successful

experimental studies in this review (Campbell et al., 2013; Dennison et al., 2004; Hinkley et al.,

2015; Taveras et al., 2011a; Taveras et al., 2011b; Yilmaz et al., 2014; Zimmerman et al., 2012)

ranged from 15 to 65 min/day with a mean of 34 min/day. Taveras et al. (2011b) found that when

motivational interviewing was used and caregivers chose to work on screen time reduction

specifically, then daily screen time was reduced by 58 min/day compared to only 36 min/day if

not specifically chosen. This improves average screen time reduction to 38 min/day across all

seven studies, which were either conducted in a primary care setting or used an intervention that

could be easily applied to the primary care setting. This is double the average calculated in the

systematic review/meta-analyses by Downing et al. (2016) for all settings with the same age

group.

The results of this integrative review support a primary care based approach to screen

time reduction in children under 6-years-old with education at the foundation of the intervention.

Providing screen time reduction education at every wellness visit up to age 5 is a solid strategy.

The intervention would last nearly 5 years over the course of 12 visits to the primary care

provider. This would be desirable because interventions of longer duration have been shown to

be more effective (Downing et al., 2016). Also, two of the studies reviewed were successful

when the intervention was conducted at the well child visits (Campbell et al., 2013; Taveras et

al., 2011a). All of the studies reviewed used similar screen time reduction topics as part of their

educational sessions that also follow the newest AAP (2016) recommendations. Incorporating
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 19

these same topics into a screen time reduction toolkit for primary care use would be beneficial.

Finally, motivational interviewing, specifically family-centered collaborative negotiation, was

successfully utilized in two of the studies and touted by Downing et al. (2016), so this would be

an useful skill to employ when discussing screen time reduction strategies with patients and their

caregivers.

Evidence Based Practice: Verification of Chosen Option

The purpose of this integrative review was to develop a toolkit that provides education

for providers and families on the adverse effects of excessive screen time on language

development in children younger than 6-years-old and evidence-based screen time reduction

strategies that can be implemented in outpatient primary care clinics at all wellness visits.

Theoretical Framework

The Health Belief Model (HBM) was selected to guide this project and explain why a

large percentage of young children spend an average of 2 hr/day or more in front of screens

despite screen time recommendations from the AAP advisory council (2016) stating no screen

time for children less than ages 18-24 months and to limit screen time to 1 hr/day for children up

to ages 2-5-years-old. The HBM was first developed for use in the public health sector to

determine how personal beliefs or perceptions influence health behavior (Hochbaum, 1958). The

model was expanded in the 1980s to include cues to action and self-efficacy to better understand

what healthcare providers can do to change perceptions, provide opportunities for subsequent

change in health behavior, and improve compliance with health-related recommendations

(Becker & Rosenstock, 1984; Janz & Becker, 1984; Rosenstock, Strecher, & Becker, 1988). The

HBM consists of four main perceptions: perceived susceptibility of the health problem,

perceived severity, perceived benefits, and perceived barriers. These four perceptions describe an
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 20

individual’s readiness for action. The expanded model includes cues to action that would activate

the individual’s readiness for action. It also includes modifying factors such as demographic,

sociopsychologic, and structural variables that may influence perception. A final concept called

self-efficacy describes the individual’s confidence in his or her own ability to perform the action.

A diagram of the chosen HBM format for this project can be located in Appendix A.

Several important questions regarding young children, screen time, and risk for language

developmental delays can be addressed within the HBM framework to help explain why

children’s screen time remains elevated and also to guide intervention (adapted from Das &

Evans, 2014):

Table 2

Assessment of Screen Time Perceptions Based on the Health Belief Model

Does the patient’s caregiver and/or healthcare provider believe that

Perceived Susceptibility excessive screen time by infants and toddlers may be associated with
language developmental delays?
Does the patient’s caregiver and/or healthcare provider believe that the
Perceived Seriousness potential consequence of a language developmental delay for their infant or
toddler from too much screen time is significant enough to try to avoid?
Does the patient’s caregiver and/or healthcare provider believe there are
Perceived Benefit benefits to decreasing screen time for infants and toddlers related to
language development?
What barriers do the patient’s caregiver and/or healthcare provider face that
Perceived Barriers prevent them from trying to decrease the amount of screen time? What can
be done to decrease these barriers?
What techniques, strategies or tools can motivate the patient’s caregiver
Cues to Action
and/or healthcare provider to decrease screen time?
How confident does the patient’s caregiver and/or healthcare provider feel
Self-Efficacy in his or her ability to decrease screen time? What can be done to increase
their confidence?

Overall, caregivers’ perceived susceptibility and perceived seriousness is low for adverse

outcomes such as language developmental delays related to young children and screen time.

Many caregivers, on the other hand, have a high perceived benefit regarding screen time, and

their perceptions are directly related to lack of knowledge. Garrison and Christakis (2005)
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 21

performed a systematic review and found no studies showing improved cognitive development

for children under 6-years-old for any educational videos, videogames, or computer programs

currently being marketed. Garrison and Christakis (2005) also identified that in regards to

television programming, there have been some studies demonstrating cognitive improvements

specific to children over 2-years-old for limited, educational programming. No television

programs have been shown to benefit cognitive development for infants and toddlers under 2-

years-old (Zimmerman, Christakis, & Meltzoff, 2007).

For pediatricians, Strasburger (2007) stated that medical residency programs do not teach

about the impact of excessive screen time on children’s cognitive development, and few

continuing medical education courses cover this topic. This lack of knowledge may also

influence providers’ perceived susceptibility and perceived seriousness of language

developmental delays for young children whose screen time exceeds 2 hr/day. Perceived barriers

may include provider-related time constraints. For those providers knowledgeable about the

potential risks of excessive screen time, they may lack the time to properly educate patients and

their families about this. There is also no standardized media use assessment tool available for

clinic use.

Goals, Objectives and Expected Outcomes

The primary goal of the DNP project was to create a toolkit for use in primary care with

evidence-based strategies to reduce screen time for children younger than 6-years-old. In order to

achieve this, three goals should be accomplished: conduct an integrative review of the literature,

create a toolkit with comprehensive resources, and present the toolkit to a group of primary care

providers. Table 3 outlines the objectives and expected outcomes for each of these goals.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 22

Table 3

DNP Project Goals, Objectives, and Expected Outcomes

Goals Objectives Expected Outcomes

1. Complete an 1. Perform a comprehensive search of the literature Complete an integrative review
integrative review of the through multiple databases using key terms. of the literature that finds
literature. 2. Select high quality studies that meet inclusion successful screen time reduction
criteria. strategies that can be
3. Review and analyze selected articles for evidence implemented in the primary
of successful screen time reduction strategies that care setting for children
can be utilized in the primary care setting for younger than 6-years-old.
children younger than 6-years-old.
2. Create an evidence- 1. Create a toolkit using findings from the Screen time reduction toolkit
based, comprehensive integrative review. created and meets all objectives.
screen time reduction 2. Include provider-directed education on the
toolkit for primary care increased risk for language developmental delays
providers. with excessive screen time for children under 6-
years-old.
3. Create a standardized screen time assessment tool
that is quick to perform.
4. Create an easy-to-follow algorithm to illustrate
use of the toolkit.
5. Create appropriate educational materials for
patients and families on adverse effects of excessive
screen time and screen time reduction strategies.
6. Include a bulleted summary of recommendations
in a brochure to assist clinicians in providing brief
but thorough patient education.
3. Deliver a high 1. The presentation will be limited to 1-hour to 1. Increase provider’s
quality, professional ensure maximal participation. This time frame knowledge about health risks of
presentation to educate includes completion of the pre-presentation survey, excessive screen time and
providers on use of the formal presentation, Q & A session, and post- screen time recommendations.
screen time reduction presentation evaluation. 2. Providers find the toolkit
toolkit. 2. Educate providers on increased risk for language educational and practical to use.
developmental delays due to excessive screen time 3. Providers are confident in
in young children and current screen time their ability to use the toolkit
recommendations. and provide screen time
3. Demonstrate use of the toolkit including reduction education to patients
algorithm, standardized assessment tool, and patient and their caregivers.
education materials.
4. Use pre-presentation surveys to assess
knowledge, attitudes, and beliefs about screen time
based on the tenets of the Health Belief Model.
5. Use post-presentation evaluations to assess value
of presentation and toolkit and knowledge gained.

Project Design and Methods

This project was developed using an integrative literature review process with an

evaluation design. Results from the integrative review were formulated into a toolkit (see
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 23

Appendix B). A presentation of the tenets of the integrative review with discussion of the toolkit

was developed (see Appendix B). The DNP student used both qualitative (informal dialogue) and

quantitative (pre-presentation survey [see Appendix C] and post-presentation evaluation [see

Appendix D]) methods for data collection and analysis.

Population, Settings and Resources

The presentation was given to staff members of the Pediatrics Clinic at Seymour Johnson

Air Force Base in Goldsboro, NC. Participants included two active duty military pediatricians,

one active duty military registered nurse, one civilian contractor registered nurse, and two active

duty military medical technicians. The Seymour Johnson Air Force Base Clinic is also known as

the 4th Medical Group (MDG) of the national Air Force Medical Service (AFMS) and offers

outpatient healthcare services to active duty military members, retirees, and their families.

Primary care services include Pediatrics, Family Health, Women’s Health, Flight Medicine, and

Mental Health. Ancillary services include Pharmacy, Laboratory, Radiology, Public Health, and

Physical Therapy. The Pediatrics Clinic has an empanelment of 1,250 patients.

Air Force (AF) medical centers are organized in a functionally similar way as their

civilian counterparts. Services are known as flights and are managed by a flight commander.

Flights are grouped together as squadrons and likewise managed by a squadron commander. All

of the squadrons together are called a group, hence 4th MDG, and is led by the group

commander, similar to a Chief Executive Officer (CEO) at a healthcare organization. Other key

executive leadership positions include the SGH (Chief of the Medical Staff), SGN (Chief Nurse),

and SGA (Administrator, Chief Operating Officer [COO], or Chief Financial Officer [CFO]).

New policies and procedures can be suggested and implemented at any level from flight to

squadron to group-wide with leadership approval. Additionally, the AFMS may mandate change
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 24

across all AF hospitals and outpatient medical centers, and all would be required to comply. In

addition to providing healthcare services for its beneficiaries, the 4th MDG prioritizes a unique

wartime medical readiness mission.

Facilitators and Barriers

A summary of the requirements for the DNP project and topic were presented to the

Pediatrics Clinic leadership in January 2017. The relevance and applicability of this project was

emphasized to the Nurse Manager and SGH to ensure support. Besides advocating for the

educational value of the toolkit and presentation, the DNP student also suggested that

implementation of the toolkit could be easily adapted into a Failure Modes and Effects Analysis

(FMEA) project facilitated by Patient Safety or a small-scale quality improvement project to

meet their Joint Commission (TJC) accreditation requirements. Both the educational value of the

toolkit and the potential for implementing a quality improvement initiative helped to facilitate

verbal approval for the toolkit presentation. Following the approval, the DNP student engaged in

informal dialogue with Pediatrics Clinic staff members about screen time recommendations and

whether this topic was discussed during wellness visits. The DNP student determined that screen

time education was not being discussed, and the primary reason was lack of education about

screen time recommendations and lack of time.

The most significant barrier encountered was deciding on a date for the presentation that

did not conflict with the patient schedule and other required military-related duties, trainings, and

exercises and allowed for a diverse group of staff members to attend. In the end, there were six

participants from the Pediatrics Clinic – two pediatricians, two registered nurses, and two

medical technicians. Staff members who were not able to attend the presentation due to

scheduling conflicts included the SGH, one nurse practitioner, and four medical technicians.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 25

Toolkit and Presentation Implementation Plan Summary

Toolkit

Pre-toolkit preparation. An integrative review was conducted on strategies to reduce

screen time for children younger than 6-years-old that can be utilized in the primary care setting.

Ten studies were included in the review, two systematic reviews/meta-analyses, five RCTs, two

pilot RCTs, and one pilot non-RCT, ranging in quality of evidence from Level IA to Level IIC.

The results of the integrative review support a primary care based approach to screen time

reduction with patient education as the primary intervention conducted at every wellness visit.

Patient education discussion topics include: screen time recommendations based on age, health

risks of excessive screen time, setting rules for use such as no screens during family meal times

or 1-hr before bedtime, co-viewing and co-using media, displacing screen time with other

activities such as reading, removing televisions and other media devices from children’s

bedrooms, and advocating for educational media and a screen-free week. Provider-directed

motivational interviewing, specifically family-centered collaborative negotiation, can be

employed in these educational discussions with patients and their caregivers to facilitate

behavioral change. These findings were used to create a toolkit for use in the primary case

setting that focused on screen time reduction in order to prevent language delays among children

under 6-years-old (see Appendix B). The DNP student also gathered information on motivational

interviewing training resources, local child development community resources, and useful

websites to include in the toolkit.

Toolkit development. The Screen Time Reduction Toolkit is a comprehensive guide that

primary care providers can use to advocate for screen time reduction for children younger than 6-

years-old (see Appendix B). Three main interventions are covered: (1) provider-directed
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 26

education on the increased risk for language developmental delays associated with excessive

screen time in children under age 6, (2) implementation of a screen time assessment at every

wellness visit, and (3) patient and caregiver education. The electronic toolkit is modeled like an

Internet web page and includes a table of contents at the beginning of the document with

hyperlinks to navigate all sections of the toolkit. A comprehensive but easy-to-follow screen time

reduction algorithm is included to illustrate how to effectively utilize the toolkit in practice. Like

the table of contents, the algorithm contains hyperlinks to various sections within the toolkit.

Most pages of the toolkit also have hyperlinks that can be used to return to the table of contents

or to the algorithm. The association between excessive screen time and language developmental

delays is described, and a summary of the findings from the integrative review of the literature is

provided. The importance of doing a screen time assessment on young children is also discussed,

especially since only 16% of pediatricians in the U. S. do this (Shifrin et al., 2015). The 2-

Question Assessment for Screen Time (2-QAST), recommended by the AAP advisory council

(2013), is presented as a time-efficient assessment to be performed at every wellness visit and

asks the following two media-related questions:

1. How much screen time does your child consume daily?

2. Is there a TV or mobile media device (tablet/iPad, cell phone, computer) in your

child’s bedroom?

Topics for discussion are showcased in various patient education formats: brochure,

poster, and family media use plan. These items can be printed and displayed or given to patients.

The brochure and poster each contain a bulleted summary of important screen time reduction

education topics to prompt providers and facilitate a brief discussion. The toolkit also contains

lists of helpful websites that can be given to families as well as local child development
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 27

community resources for provider referrals. Motivational interviewing resources and the 2016

AAP policy statement and technical report are also embedded references.

Presentation

After developing the Screen Time Reduction Toolkit, an educational PowerPoint (PPT)

presentation was created (see Appendix B). The presentation discussed the risk for language

developmental delays with excessive screen time in children younger than 6-years-old and

described the current screen time recommendations for young children. The presentation

included a summary of the integrative review findings on screen time reduction strategies in the

primary care setting and use of the algorithm and 2-QAST tool. A hyperlink to the actual

electronic toolkit was also included so that the DNP student could display and navigate the

document during the presentation.

A 1-hr presentation was given to all available Pediatric Clinic staff members on March 6,

2017. Lunch was provided to encourage participation. The presentation included a pre-

presentation survey and a post-presentation evaluation and allowed time for a question and

answer session at the end. Copies of the brochure and poster were given to attendees. After the

presentation was completed, the DNP student provided the clinic with an electronic copy of the

Screen Time Reduction Toolkit.

Evaluation

Pre-presentation survey. The pre-presentation survey consisted of 10 questions with a

mix of numerical responses, Likert scale questions, and short answer responses. Four of the

questions were aligned with the six attributes of the HBM and were intended to measure staff

members’ readiness for action in implementing a screen time reduction intervention by assessing

perceived susceptibility (Q5), perceived seriousness (Q6), perceived benefit (Q7), and perceived
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 28

barriers (Q9). Self-efficacy (Q8) and cues to action (Q10) were included to determine self-

confidence with a potential screen time intervention and what would motivate them to carry out

the intervention. Research compiled by the AAP advisory council (2013) showed that providers

who watch more television were less likely to recommend that their patients and families

decrease their television viewing. Therefore, four questions were included for staff members to

assess their personal daily screen time habits, personal perceptions of screen time habits of

young children, and knowledge about current screen time recommendations. The pre-

presentation surveys were administered and completed before the presentation was started.

Post-presentation evaluation. The post-presentation evaluation consisted of 10

questions asking staff members to evaluate whether the presenter: (1) clearly communicated their

purpose, (2) was organized, (3) had a good understanding of the topic, (4) was well-prepared, (5)

spoke clearly, (6) used time effectively, (7) had an informative presentation, (8) responded

effectively to questions, (9) was engaging, and (10) enhanced understanding and knowledge

about screen time recommendations and potential developmental risks. Possible responses were

“yes”, “needs work”, and “no” with the option to add additional comments if desired. There were

two additional short answer feedback questions asking them what they liked most about the

presentation and areas for improvement. The post-presentation evaluations were administered

and completed immediately following the presentation and question and answer session.

Data Analysis

Descriptive statistics were used to analyze the data. The responses from the surveys were

entered into table format in Excel. Calculations were made as applicable such as sums and

averages. Short answer responses were organized and grouped by common themes.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 29

Results

Pre-presentation survey. Six pre-presentation surveys were completed by two

pediatricians, two pediatric registered nurses, and two medical technicians. A majority of the

staff members (83%) had high perceived susceptibility, perceived seriousness and perceived

benefit regarding excessive screen time and language delays representing a high readiness for

action among them. Regarding perceived susceptibility, 83% of staff members agreed or strongly

agreed that excessive screen time by children younger than 6-years-old may be associated with

language developmental delays; one participant (17%) disagreed. Regarding perceived

seriousness, 83% of staff members agreed or strongly agreed that it was important to try to avoid

too much screen time for children younger than 6-years-old because of the potential

consequences of a language developmental delay; one participant (17%) neither agreed nor

disagreed. Regarding perceived benefit, 100% of staff members agreed or strongly agreed that

decreasing screen time for children younger than 6-years-old is beneficial for language

development. Staff members also responded with the following perceived barriers: (1) time

constraints during wellness visits, (2) not having enough personal knowledge about the

developmental risks associated with too much screen time, and (3) parental resistance to screen

time reduction advice.

In order to activate this readiness for action, self-efficacy and cues to action were

assessed. Regarding self-efficacy, 83% of staff members agreed or strongly agreed that they were

confident in their ability to discuss screen time with families; one staff member disagreed (17%).

Regarding cues to action, staff members were asked what techniques, strategies, or tools would

motivate them to discuss screen time with families. They responded with the following:

(1) visual aids, handouts, and short videos that can be quickly utilized to educate patients and
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 30

their families during wellness visits, (2) offering age-appropriate books in the clinic such as

Reach Out and Read, (3) better education for staff members about the developmental risks

associated with too much screen time, and (4) increasing time for wellness visit to 30 min to

allow for more education and discussion. Because the majority of the staff members (83%)

already have a high level of confidence with this subject, proper education and tools would make

a screen time reduction intervention possible to implement.

In response to the self-assessment questions, the staff members had a screen time average

of 3.4 hr/day during the weekdays and 4.6 hr/day on the weekends. This screen time is outside of

regular work hours. Only 33% of staff members agreed with the statement, “I should reduce my

screen time”. Another 33% of staff members disagreed with that statement, and an additional

33% of staff members neither agreed nor disagreed. Regarding their perception of how much

screen time children younger than 6-years-old actually engage in, the average response from

67% of staff members was 3.3 hr/day during the weekdays and 4.8 hr/day on the weekends.

Thirty-three percent of staff members did not respond; they believed the question did not apply

to them because they did not have young children living in their homes. Regarding actual screen

time recommendations for children younger than 6-years-old, the responses ranged from 0-2

hr/day with an average response of 0.7 hr/day for children under age 2 and 1.5 hr/day for

children ages 2-5. All of these responses support the need for improved staff member education

about screen time recommendations and the potential adverse health risks of too much screen

time.

Post-presentation evaluation. The post-presentation evaluations were administered to

and completed by all six staff members immediately following the presentation and question and

answer session. All six staff members responded yes to the first 10 questions. Additional
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 31

feedback included “excellent brochure”, “brochure is fantastic”, “algorithm is great, easy to use

and follow”, “information presented in an easy to understand manner”, and “excellent slides and

quality of patient education handouts”.

Outcomes

Prior to implementation of the DNP project, three goals and expected outcomes were

identified (see Goals, Objectives, and Expected Outcomes section). These three goals and the

actual outcomes are discussed below.

Goal 1. Complete an Integrative Review of the Literature

The integrative review of the literature was completed and found successful screen time

reduction strategies that can be implemented in the primary care setting for children younger than

6-years-old. Ten studies were selected, reviewed, and analyzed based on key terms and

appropriate inclusion and exclusion criteria. The studies included two systematic reviews/meta-

analyses, five RCTs, two pilot RCTs, and one pilot non-RCT, ranging in quality of evidence

from Level IA to Level IIC. Education for providers and families was the primary intervention

with many of the research studies sharing common educational topics that were also in line with

the AAP advisory council’s 2016 policy statement about screen time and their recommendations.

A long-lasting intervention over the course of several visits was more successful than a one-time

intervention. The use of motivational interviewing also resulted in an increased reduction in

screen time. The results of the integrative review support a primary care based approach to

screen time reduction with patient education as the primary intervention conducted at every

wellness visit.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 32

Goal 2. Create an Evidence-Based, Comprehensive Screen Time Reduction Toolkit for

Primary Care Providers

From the integrative review findings, a screen time reduction toolkit was successfully

created. The toolkit includes education for providers about increased risk for language delays

with excessive screen time in children younger than 6-years-old and evidence-based strategies to

reduce screen time. The 2-QAST, a standardized screen time assessment tool that is quick and

efficient to perform, is included in the toolkit. Additionally, the DNP student created a screen

time reduction algorithm to guide patient education and referrals. Per the post-presentation

evaluations, staff members found the algorithm helpful and easy to use. Appropriate educational

materials were created to include a Family Media Use Plan (adapted from the AAP), a brochure,

a poster, and a list of useful websites to give to families. The brochure and poster include a

bulleted summary of screen time reduction recommendations allowing for clinician ease of use.

Per the post-presentation evaluation responses, staff members were impressed with the

educational materials, especially the brochure.

Goal 3. Deliver a High Quality, Professional Presentation to Educate Providers on Use of

the Screen Time Reduction Toolkit

A presentation of the toolkit with a summary of the DNP project and integrative review

findings was given to pediatric staff members and met all objectives. Participants included two

pediatricians, two pediatric registered nurses, and two medical technicians. The presentation was

limited to 1 hr to ensure maximal participation and included a pre-presentation survey and post-

presentation evaluation. The post-presentation evaluations showed that staff members found the

presentation timely, educational, and professional. They found the slides informative and

believed the presentation enhanced their understanding and knowledge about screen time
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 33

recommendations and reduction strategies. A question and answer session after the presentation

addressed any unclear information and allowed for more discussion on how the clinic could

improve its process in providing more education during wellness visits. An electronic copy of the

toolkit was burned to a CD-ROM and given to the Pediatric Clinic’s Nurse Manager for

implementation.

Discussion

Influence on Knowledge and Beliefs

The HBM served as the framework for this educational intervention. According to the

model, health-promoting behavior is triggered when the perceived severity, perceived

susceptibility, and perceived benefit of a health behavior coupled with cues to action overcome

perceived barriers. For this intervention to be applied successfully in the primary care setting,

providers must believe that excessive screen time for young children is a significant issue

because it increases their risk for language developmental delays and other health problems.

They must also believe that screen time reduction education is beneficial and be confident in

their ability to discuss screen time with patients and their families. Additionally, providers must

be given useful tools and techniques to provide this education in an effective and efficient way.

Finally, providers must believe that these tools and techniques will be enough to overcome any

barriers.

The pre-presentation survey, created after the HBM, was important to this project

because it assessed staff members’ perceptions about the importance of screen time reduction,

clinical barriers they faced that prevented them from doing screen time education, and what they

felt would be useful in order to perform screen time reduction education. Overall, staff members

had high perceived seriousness (83%), perceived susceptibility (83%), and perceived benefit
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 34

(100%). This was a very positive finding. Staff members’ attitudes and beliefs about screen time

for young children were in agreement with the principles of this project. Attitudes and beliefs are

not easy to change; however, the barriers they identified were more concrete and can be

overcome. Two of the barriers identified included not having enough personal knowledge about

the developmental risks associated with too much screen time and the potential for parental

resistance to screen time reduction advice. The toolkit includes education for clinicians and

patient education handouts. These resources will improve staff members’ knowledge, thereby

boosting their confidence and ability to discuss screen time with families. Also, the patient

education handouts are an excellent way to diffuse resistance because staff members can tell

parents to read the information at their own leisure. The third barrier identified was time

constraints during wellness visits. Unfortunately, no policy or procedure changes were made in

the clinic as part of this project. Still, the patient education brochure and poster contain a bulleted

summary of screen time reduction strategies, which makes providing screen time education

organized and quick to deliver in just a few minutes. The barriers disappear when the toolkit is

used in its full capacity.

Finally, cues to action are the tools or techniques that would actually trigger staff

members to implement screen time reduction education during wellness visits. As staff members

requested in the pre-presentation surveys, the toolkit includes visual aids, handouts, and

education for staff members about the developmental risks associated with too much screen time.

One staff member suggested having patients watch an educational video covering several

anticipatory guidance topics. An educational video to accompany this toolkit would be an

excellent project to pursue in the future. Also, staff members again requested increasing the time

for wellness visits to 30 min. Although no changes to clinic policies or procedures were made,
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 35

the patient education handouts, especially the poster and brochure, were designed to provide

information quickly to patients and their families with minimal impact on the visit. The toolkit

and patient education resources are in line with the cues to action identified by the staff members

on their pre-presentation surveys. Staff members already believe screen time is an issue for

young children and is associated with health risks. The toolkit dissolves barriers and addresses a

majority of the cues to action identified by staff members. In fact, the post-presentation

evaluations revealed that all staff members felt the presentation was informative and increased

their knowledge and understanding of the topic. Staff members were impressed with the quality

of the patient education handouts and found the algorithm easy to navigate. Therefore, there is a

high likelihood for the clinic to successfully implement the toolkit and improve screen time

education for staff members, patients, and their families.

Use of the Integrative Review and Screen Time Reduction Toolkit

The Screen Time Reduction Toolkit is useful in all pediatric primary care settings and

inexpensive in its application. The purpose of the toolkit is to educate providers and families

about health risks, specifically language developmental delays, that can result from excessive

screen time, current screen time recommendations, and evidence-based strategies that can be

used to reduce screen time. The toolkit’s algorithm guides providers through a quick assessment

of screen time behaviors called the 2-QAST and includes screen time education appropriate to

the patient’s age. The algorithm also lists the patient education resources included in the toolkit

as well as online resources and community services. The DNP student recommends that a screen

time assessment be performed and education be given at every wellness visit from 2-months-old

to 5-years-old.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 36

Before implementing this toolkit, the DNP student recommends completion of the pre-

presentation survey to assess for perceived barriers and cues to action. This information will be

useful to individualize the implementation of the toolkit to the specific needs of the clinic and its

providers. Only 16% of pediatric providers discuss screen time with patients and their families,

which is extremely low. The DNP student hopes to significantly improve this rate through use of

the toolkit to enhance providers’ knowledge about screen time and thereby improve their

confidence in providing screen time education and empower them to act as advocates for screen

time reduction. Multiple educational discussions about screen time with providers may

ultimately influence parents to properly manage their children’s screen time at home.

Limitations

Conducting the pre-presentation survey as part of a focus group to help guide the creation

of the toolkit would have been a useful endeavor and allowed for some additional discussion

time. Survey results and comments from the discussion could have then be incorporated into the

toolkit design at its inception. Also, only six staff members were able to attend. More

participants would have allowed for additional feedback regarding perceived barriers and more

ideas for cues to action. Due to academic time constraints, this DNP project was limited to an

educational intervention. With more time, the clinic would be given the option to implement the

toolkit on their own, and then complete follow-up surveys a few months later to evaluate its

effectiveness in practice.

Finally, the integrative review was specific to screen time reduction strategies for

children under 6-years-old, and the association between excessive screen time and language

developmental delays was the only health risk studied. Therefore, the toolkit may not be practical
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 37

for use with other age groups or for preventing other health problems known to be associated

with excessive screen time.

Future Recommendations

Because this project was an educational intervention, the next step is to actually

implement the toolkit and evaluate its usefulness in practice. Also, creating a screen time

educational video aligned with the toolkit and shown to patients and their families as part of the

wellness visit would be another intervention to pursue. Finally, collecting actual data on whether

implementation of the toolkit decreased screen time among young children as expected would

further support clinical use of the toolkit.

A delay in language development is only one of the many developmental, physical, and

psychosocial adverse effects associated with excessive screen time, including aggressive and

violent behavior, obesity, and smoking. This toolkit serves as a foundational resource to be

expanded and enhanced through post-doctoral work such as adding more interventions to the

algorithm to address additional health risks.

Ethics and Human Subjects Protection

This project was deemed exempt from Internal Review Board (IRB) approval (see

Appendix E). The project did not involve any interaction or intervention with patients, family

members, or medical records. The presentation of the integrative review findings and toolkit was

to outpatient pediatric providers, registered nurses, and medical technicians. Participation was

100% voluntary. The data collected was an assessment of knowledge and personal opinions

about the presentation topic.

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 38

Conclusion

With new screen technologies constantly being developed, childhood is becoming

increasingly enveloped into a digital world. Many research studies have proven that excessive

screen time is associated with increased health risks, especially in early childhood where face-to-

face human interaction is crucial for language development. Members of the AAP have been

releasing policy statements concerning the effects of children’s media use since 1984 when the

Task Force for Children and Television was created. Despite increasing opportunities for screen

time and evidence on the risks of too much screen time, an astounding 84% of primary care

providers do not advocate for screen time reduction during clinic visits. This may partially

explain why a majority of young children watch 4-5 hours of television daily; their caregivers

may not know the risks involved.

The most important immediate action is to increase the number of providers who give

screen time education to patients and their families. Knowledge empowers change. The toolkit

provides the education that providers need to be knowledgeable as well as confident in their

ability to discuss screen time with families. The 2-QAST is simple, easy to remember, and

applies to all patients. The algorithm guides providers to additional resources they can use to

refer their patients to community services. The patient education handouts make the information

more accessible in an organized and easy-to-follow format. Being consistent about providing a

few minutes of screen time education at every wellness visit from 2-months-old to 5-years-old

sets a solid foundation for parents and children to create healthier screen time habits at home.
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 39

References

American Academy of Pediatrics. (2011). Media use by children younger than 2 years.

Pediatrics, 128(5), 1040-1045.

American Academy of Pediatrics. (2013). Policy statement: Children, adolescents, and the

media. Pediatrics, 132(5), 958-961.

American Academy of Pediatrics. (2016). Policy statement: Media and young minds. Pediatrics,

138(5), 1-6.

Beck, A. L., Takayama, J., Badiner, N., & Halpern-Felsher, B. (2015). Latino parents beliefs

about television-viewing by infants and toddlers. Journal of Health Care for the Poor

and Underserved, 26, 463-474.

Becker, M. H., & Rosenstock, I. M. (1984). Compliance with medical advice. In A. Steptoe & A.

Matthews (ed.). Health Care and Human Behavior. London: Academic Press. Pp. 135-

152.

Birken, C. S., Maguire, J., Mekky, M., Manlhiot, C., Beck, C. E., DeGroot, J., . . . Parkin, P.

(2012). Office-based randomized controlled trial to reduce screen time in preschool

children. Pediatrics, 130(6), 1110-1115.

Campbell, K. J., Lioret, S., McNaughton, S. A., Crawford, D. A., Salmon, J., Ball, K., . . .

Hesketh, K. D. (2013). A parent-focused intervention to reduce infant obesity risk

behaviors: A randomized trial. Pediatrics, 131(4), 652-660.

Chonchaiya, W., & Pruksananonda, C. (2008). Television viewing associates with delayed

language development. Acta Paediatrica, 97, 977-982.

Christakis, D. (2015, September 11). When it comes to kids, is all screen time equal? [Video

file]. TEDx Talks. Retrieved from https://youtu.be/BoT7qH_uVNo

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Christakis, D. A., Gilkerson, J., Richards, J. A., Zimmerman, F. J., Garrison, M. M., Xu, D., . . .

Yapanel, U. (2009). Audible television and decreased adult words, infant vocalizations,

and conversational turns: A population-based study. Archives of Pediatrics and

Adolescent Medicine, 163(6), 554-558.

Das, B. M., & Evans, E. M. (2014). Understanding weight management perceptions in first-year

college students using the health belief model. Journal of American College Health,

62(7), 490.

Dearholt, S., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Models and

guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International. Retreived from

http://www.hopkinsmedicine.org/evidence-based-practice/jhn_ebp.html

Dennison, B. A., Russo, T. J., Burdick, P. A., & Jenkins, P. L. (2004). An intervention to reduce

television viewing by preschool children. Archives of Pediatrics and Adolescent

Medicine, 158(2), 170-176.

Downing, K. L., Hnatiuk, J. A., Hinkley, T., Salmon, J., & Hesketh, K. D. (2016). Interventions

to reduce sedentary behaviour in 0-5-year-olds: A systematic review and meta-analysis of

randomised controlled trials. British Journal of Sports Medicine, 0, 1-9.

Duch, H., Fisher, E. M., Ensari, I., Font, M., Harrington, A., Taromino, C., . . . Rodriguez, C.

(2013). Association of screen time use and language development in hispanic toddlers: A

cross-sectional and longitudinal study. Clinical Pediatrics, 52(9), 857-865.

Garrison, M .M., & Christakis, D. A. (2005). A teacher in the living room? Educational media

for babies, toddlers, and preschoolers. Menlo Park, CA: Kaiser Family Foundation.

Hinkley, T., Cliff, D. P., & Okely, A. D. (2015). Reducing electronic media use in 2-3 year-old

children: Feasibility and efficacy of the Family@play pilot randomised controlled trial.
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BMC Health, 15(779), 1-12.

Hochbaum, G. M. (1958). Public Participation in Medical Screening Program: A Socio-

psychological Study (Public Health Service Publication No. 572). Washington, DC:

Government Printing Office.

Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A decade later. Health

Education Quarterly, 11(1), 1-47.

Kuhl, P. K. (2004). Early language acquisition: Cracking the speech code. Nature Reviews, 5,

831-843.

Lin, L. Y., Cherng, R. J, Chen, Y. J., Chen, Y. J., & Yang, H. M. (2015). Effects of television

exposure on developmental skills among young children. Infant Behavior and

Development, 38, 20-26.

Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health

Belief Model. Health Education Quarterly, 15(2), 175-183.

Schoon, I., Parsons, S., Rush, R., & Law, J. (2010). Children’s language ability and

psycholosocial development: A 29-year follow-up study. Pediatrics, 126(1), e73-e80.

Shifrin, D., Brown, A., Hill, D., Jana, L., & Flinn, S. K. (2015, October 1). Growing up digital:

Media research symposium. American Academy of Pediatrics.

Strasburger, V. C. (2007). First do no harm: Why have parents and pediatricians missed the boat

on children and media? The Journal of Pediatrics, 151, 334-336.

Tanimura, M., Okuma, K., & Kyoshima, K. (2007). Television viewing, reduced parental

utterance, and delayed speech development in infants and young children. Archives of

Pediatric and Adolescent Medicine, 161, 618-619.

Taveras, E. M., Gillman, M. W., & McDonald, J. (2011). First steps for mommy and me: A pilot
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intervention to imrpove nutrition and physical activity behaviors of postpartum mothers

and their infants. Maternal Child Health, 15, 1217-1227.

Taveras, E. M., Gortmaker, S. L., Hohman, K. H., Horan, C. M., Kleinman, K. P.,

Mitchell, K., . . . Gillman, M. W. (2011). Randomized controlled trial to improve primary

care to prevent and manage childhood obesity. Archives of Pediatric Adolescent

Medicine, 165(8), 714-722.

Vandewater, E. A., Bickham, D. S., Lee, J. H., Cummings, H. M., Wartella, E. A., & Rideout, V.

J. (2005). When the television is always on: heavy television exposure and young

children’s development. American Behavioral Scientist, 48(5), 562-577.

Wahi, G., Parkin, P. C., Beyene, J., Uleryk, E. M., & Birkne, C. (2011). Effectiveness of

interventions aimed at reducing screen time in children: A systematic review and meta-

analysis of randomized controlled trials. Archives of Pediatrics and Adolescent Medicine,

165(11), 979-986.

Yilmaz, G., Caylan, N. D., & Karacan, C. D. (2014). An intervention to preschool children for

reducing screen time: A randomized controlled trial. Child: Care, Health and

Development, 41(3), 443-449.

Zimmerman, F. J., Ortiz, S. E., Christakis, D. A., & Elkun, D. (2012). The value of social-

cognitive theory to reducing preschool TV viewing: A pilot randomized trial. Preventive

Medicine, 54, 212-218.

Zimmerman, F. J., Christakis, D. A., & Meltzoff, A. N. (2007). Associations between media

viewing and language development in children under age 2 years. The Journal of

Pediatrics, 151, 364-368.

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 43

Appendix A

Health Belief Model: Chosen Format for Use in This Project

Figure 1. Chosen format of the Health Belief Model used as the theoretical framework for the

DNP project. Reprinted from Health Behavior and Health Education: Theory, Research, and

Practice (4th ed.). K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), 2008, Retrieved from

http://www.med.upenn.edu/hbhe4/part2-ch3-main-constructs.shtml. Copyright 2008 by John

Wiley & Sons, Inc.

Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 44

Appendix B

Toolkit and Presentation

 45

Reducing Screen Time for

Children Under Age 6 to
Prevent Language Delays
A Toolkit for Primary Care Providers

MARCH 2017
Cristina E. Kuta, DNPc, RN
University of Massachusetts Amherst, College of Nursing
Email: [email protected]
 46

REDUCING SCREEN TIME FOR CHILDREN UNDER

AGE 6 TO PREVENT LANGUAGE DELAYS
A Toolkit for Primary Care Providers
Table of Contents

Acknowledgements.…..………….………………………………………………………… 4

Toolkit At-a-Glance.………………...…….……………….………………………………… 5
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Introduction.…………………………………………………………………………………... 6

Purpose.…………………………………………………………….………………..… 6

How does excessive screen time affect language development?.………. 6

What does the AAP recommend for screen time; how much screen time

are young children actually being exposed to on a daily basis?...... 8

What opportunities exist in primary care to address screen time with

families?.……………………………………………………………………….. 9

Evidence-Based Strategies to Reduce Screen Time.………………………..………. 10

Screen Time Reduction Algorithm………………………………………………...…….. 12

Actions for Primary Care Providers.….………..…..…………………………………….. 13

Family-Centered Collaborative Negotiation Overview.…………………...……….. 15

Conclusion.………………………………………………………..…………………...…….. 16

2-Question Assessment for Screen Time (2-QAST).……………………………..…….. 17

Motivational Interviewing Resources.………………………………………………..…. 19

Article: Family-Centered Collaborative Negotiation (Tyler & Horner, 2008)......... 20

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2
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Patient Education.…………………………………………………………………..……… 31

Brochure.…………………………………………………………………………...… 31

Poster.……………………………………………………………………………....… 34

Family Media Use Plan.……………………………….…………………………… 36

Websites for Families.………………….………………………………………….... 40

Child Development Community Resources for Wayne County……..…..….......... 41

AAP 2016 Policy Statement: Media and Young Minds.……………………..………. 42

Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

AAP 2016 Technical Report: Children and Adolescents and Digital Media.….... 49

PowerPoint Presentation.……………………………………………………………..…… 68

References.…………………………………………………………………………….…….. 99

Toolkit Disclaimer: The Screen Time Reduction Toolkit was compiled by Cristina E. Kuta,
DNPc. Specific components of the toolkit were created by the author, as cited. Sources for
the narrative sections of the toolkit are cited in References. Photos, website links, and
articles included in the toolkit are public record.

3
 48

Acknowledgements
Thank you to Dr. Jean DeMartinis, PhD, FNP-BC, who served as chairperson for
my capstone project as well as my advisor throughout the course of my DNP-
FNP program. This toolkit was made possible by her expert guidance and
editorial eye.

Thank you to the Pediatric Clinic staff members at Seymour Johnson Air Force
Base in Goldsboro, NC. Their feedback was instrumental in verifying that the
toolkit is timely, practical, and user-friendly.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Thank you to my husband, Matthew Kuta, whose love and unending

encouragement motivated me through this project.

Finally, a special thank you to my daughter, Sophie, who inspired me to think

more deeply about how screen time affects growing young minds.

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Toolkit At-a-Glance
This electronic toolkit is a Academy of Pediatrics (AAP) advisory
comprehensive, easy-to-use guide council in 2013, is presented as a time-
that pediatric primary care providers efficient assessment to be performed
can use to advocate for screen time at every wellness visit. Topics for
reduction for children discussion are showcased in
younger than 6-years-old. various patient education
The toolkit is modeled like formats: brochure, poster,
an Internet web page and and family media use plan.
includes hyperlinks These items can be printed
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embedded throughout and displayed or given to

the document to navigate patients. The brochure and
all sections of the toolkit. A poster each contain a
screen time reduction bulleted summary of
algorithm is included to important screen time
illustrate how to reduction
effectively QUICK LINKS: education topics
utilize this toolkit to prompt
Brochure
in practice. providers and
Provider Poster facilitate brief
education on discussion. The
Family Media Use Plan
the association toolkit also
between AAP 2016 Policy Statement contains lists of
excessive helpful websites
screen time and language that can be given to families as well as
developmental delays is described, local child development community
and a summary of the findings from an resources for provider referrals.
integrative review of the literature is Motivational interviewing resources
provided. The 2-Question Assessment and the 2016 AAP policy statement
for Screen Time (2-QAST), and technical report are also
recommended by the American embedded references.

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Introduction
Purpose
The purpose of this toolkit is to provide education for pediatric primary
care providers, patients and their families on the adverse effects of excessive
screen time on language development in children younger than 6-years-old
and evidence-based screen time reduction strategies that can be implemented
in outpatient primary care clinics at all wellness visits.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

How does excessive screen time affect language development?

Language development and vocabulary growth in children younger than
6-years-old are directly related to the amount of time parents spend speaking to
them. Therefore, excessive screen time can interfere with a young child's
language development because parents spend less time interacting with and
talking to their child. This is a significant issue because language development is
biologically correlated to age, and these early years are crucial for language
acquisition, especially phonetics and syntax. Furthermore, receptive language
delays by age 5 are a significant risk factor for social and emotional problems in
adulthood.
Several studies have supported this association between screen time in
children under 6-years-old and language delays. Children ages 15 to 35 months
who were exposed to 137 min/day of television were 3.3 times more likely to

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develop a language developmental delay compared to children who watched

less than 20 min/day of television. Hispanic infants and toddlers who watched
more than 2 hr/day had 5.5 times the risk of scoring lower in communication on
the ASQ-3 after 1 year compared to those children who watched less than 2 hr/
day. Furthermore, children who started watching television before 12 months of
age and watched more than 2 hr/day were 6 times more likely to develop a
language delay. Although studies on the relationship between screen time and
language development are few and mostly limited to observational or quasi-
experimental methods, findings have remained consistent that increased screen
time is associated with an increased risk for language developmental delays.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Human interaction has a strong influence on a young child’s language

development. Infants, specifically, learn best from live sessions versus televised
ones, and social feedback is an important predictor for the quantity and quality
of infant vocalizations. For children younger than 6-years-old, screen time
disrupts the social experience of learning language and prevents opportunities
for caregivers to model two-way conversation and convey thoughts in
sentences rather than single words. In a group of 2-3-year-old children, for every
1 hr of television watched, the children were exposed to 500-1000 fewer words.
The children also had significant reductions in their vocalizations, vocalization
duration, and conversational turns with more time spent watching television.
Also, parents frequently spoke in shorter, one-word sentences and spoke less
words overall to their children when the television was on.
The amount of time caregivers interact and converse with their children is
also associated with risk for developing language delays. Children with
documented language delays spent an average of 7 hr/day with their
caregivers in which 3.6 of those hours were spent in conversation compared to
children with normal language development who spent an average of 9.3
hr/day with their caregivers in which 5.8 of those hours were spent in

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conversation. Furthermore, children who watched television alone were 8.5

times more likely to develop a language delay.

What does the AAP recommend for screen time, and how much
screen time are young children actually being exposed to on a daily
basis?
The AAP recognizes the health implications of too much screen time. In
addition to language delays, children are at increased risk for obesity, violence
and aggression, loss of social skills, attention problems, anxiety and depression,
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

sleep deprivation, vision problems, migraine headaches, repetitive motion

syndrome and arthritis. In January 2017, the AAP created an online Media and
Children Communication Toolkit, which encourages families to create a media
use plan to gain awareness of media use habits and adopt methods to
decrease use. In their most recent 2016 policy statement, the AAP advocates
for no screen time in children under the age of 18-24 months, other than video-
chatting, and to limit screen time to less than 1 hr/day of high-quality
programming and apps for children ages 2-5 because of the harmful impact it
might have on the developing brain. They also recommend caregivers co-view
and co-use media, not allow screen time during meals or for 1 hr before
bedtime, and remove TVs and other media devices from children’s bedrooms.
Still, according to parent surveys, 90% of children younger than 2-years-old are
exposed to 1 to 2 hr/day of television with 14% of them watching greater than 2
hr/day of television. Thirty-eight percent of infants use mobile devices like
smartphones. The typical American child before age 5 watches 4.5 hr/day of
television.
Many caregivers believe that screen media can have a positive impact
on their child’s cognitive development because many programs and products
advertise this as a benefit. Caregivers who believe a television program or video

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is educational and important to healthy development are twice as likely to have

the television on for extended periods of time. An interview with a group of
Hispanic families found limited knowledge among caregivers about the
potential risks of too much screen time, but the caregivers also reported they
would reduce their children’s screen time if they were better educated about
this issue. Improved education and awareness about the potential for language
delays in young children due to excessive screen time can empower families to
reduce screen time in their homes.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

What opportunities exist in primary care to address screen time with

families?
The primary care setting offers excellent opportunities to promote screen
reduction education to young children and their families. From birth to age 5,
children will see their provider a minimum of 12 times for routine wellness visits.
Despite this opportunity only 16% of pediatricians in the United States ask
patients and their families about their media use, and this statistic has not
changed in the last 20 years despite the production of new devices providing
more opportunities for screen time, including tablets, portable DVD players, and
smartphones. This toolkit offers primary care providers a timesaving approach to
assessing children’s screen time during routine wellness visits and provides
education for providers and families to raise awareness about the risks of
excessive screen time for young children and evidence-based strategies to
decrease screen time in the home.

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Evidence-Based Strategies to Reduce Screen Time

The findings from an integrative review of 10 studies were used to create

this toolkit. The integrative review included 2 systematic review/meta-analyses, 4
randomized controlled trials [RCT], 2 pilot RCTs, and 1 pilot non-RCT. There were
significant reductions in screen time by an average of 34 min/day across 9 of
these studies using a mix of the following interventions:

1. Recurrent education using family-centered collaborative negotiation and

Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

printed materials over multiple visits about screen time recommendations

and to improve knowledge about excessive screen time and risks of
language delay
2. Setting rules for use – i.e. no screens during family mealtimes or for 1 hour
before bed
3. Co-viewing and co-using high-quality media programming and apps with
children
4. Displacing screen time with other activities – i.e. reading books, creative
play
5. Removing TVs and other media devices from children’s bedrooms

Of the seven experimental studies, four studies (3 RCTs, 1 pilot non-RCT) applied
interventions in the primary care setting. The interventions in the remaining three
studies (1 RCT, 2 pilot RCTs) were applied in daycare/preschool- and
community-based settings. These studies were included in the integrative review
because the interventions were similar and could be easily translated to the
primary care setting.

Sources: Birken et al., 2012; Campbell et al., 2013; Dennison et al., 2004; Downing et al., 2016; Hinkley et al., 2015; Taveras
et al., 2011a; Taveras et al., 2011b; Wahi et al., 2011; Yilmaz et al., 2014; Zimmerman et al., 2012

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Screen Time Reduction

ALGORITHM

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Screen Time Reduction Algorithm
Age-appropriate history,
relevant screening tools Perform 2-Question
(i.e. ASQ-3, MCHAT-R), Conduct screen Tools to guide
Assessment for time educational discussion
and physical exam Screen Time discussion with
(2-QAST) caregivers
-click here- Click here for
Brochure
Click here for
Risk for or existing Motivational
language Interviewing (MI) Click here for
developmental delay Training Resources Poster

Click here for

Specifically, use Family-
Family Media
Centered Collaborative
Click here for Use Plan
Negotiation (type of MI).
Child Development -click here for article-
Community
Resources
No screen time, <18-24 Co-use & co-view
except video months media
chat old
Encourage Set rules: No
alternative screen time
<1 hr/day HIGH 2-5
activities and during family
quality screen years
daily reading meals and 1-hr
time old
before bed

Legend:
Click here for direct route No TVs or media
Websites for indirect route devices in
Families Click here for Table of Contents bedroom
© 2017 Cristina Kuta
 57

Actions for Primary Care Providers

The 2-Question Assessment for Screen Time (2-QAST), recommended by the AAP
in 2013, is a simple way to initiate dialogue between primary care providers and
families about screen time (see page 17-18):

1. How much screen time (min/hr) does your child consume daily?
2. Is there a TV or mobile media device (tablet/iPad, cell phone, computer)
in your child’s bedroom?

The 2-QAST should be added to the encounter template for all 12 routine
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

wellness visits from age 2-months to 5-years. The provider should use family-
centered collaborative negotiation (see pages 19 and 20-30) to engage
caregivers in brief educational discussions about the AAP screen time
recommendations, risk for language developmental delays with excessive
screen time, and strategies for reducing screen time in the home. The discussion
should include the following:

1. Excessive screen time leads to increased risk of language developmental

delays in children younger than 6-years-old.
2. Discourage screen time for children younger than 18-24 months, except
video-chat.
3. Encourage a 1-hour daily limit of high-quality screen time for children 2- to
5-years-old. Direct families to Common Sense Media at
www.commonsensemedia.org to find age-appropriate high-quality
media including movies, games, apps, websites, TV shows, books, and
music from over 20,000 listings.
4. Encourage parents to create a Family Media Use Plan at:
www.healthychildren.org/mediauseplan

5. Encourage caregivers to view and use media with their child.

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6. Encourage caregivers to read to their children for at least 20 min/day

using an interactive approach.
7. Encourage caregivers to not allow screens during family meal times and
for 1-hour before bedtime.
8. Encourage caregivers to remove televisions and other media devices
(tablets/iPads, cell phones, computers) from their child’s bedroom.

The provider can also use printed brochures (see pages 31-33) or posters (see
pages 34-35) to facilitate the discussion. If a caregiver is unable to access or
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

print out their personalized online Family Media Use Plan, providers can supply
the caregiver with a paper copy (see page 36-39). Providers should also direct
caregivers to educational websites that discuss the importance of screen time
reduction, screen time reduction strategies, and high-quality screen time options
(see page 40).

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Family-Centered Collaborative Negotiation Overview

Family-centered collaborative negotiation is a form of Motivational
Interviewing (MI) designed to be brief, taking 5-15 min, making it appropriate
and effective for the primary care setting. The objective of this type of
communication is to promote healthy behaviors like screen time reduction. In
family-centered collaborative negotiation, the provider assumes an empathetic
and collaborative partnership with the family rather than the traditional
objective and prescriptive approach. The family should actively participate in
the discussion, and, in the end, decide what changes they will make in creating
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

a healthier lifestyle. The following table describes the basic principles of family-
centered collaborative negotiation and how providers can use these principles
when approaching patients and their families about lifestyle changes, especially
screen time reduction. A case example of this process can be reviewed on
pages 20-30 of this toolkit. MI resources can be found on page 19 of this toolkit.

Principles
• Be patient-centered
• Establish a partnership with the patient and their family
• Develop discrepancy between current behavior and lifestyle goals
• Explore and resolve ambivalence about engaging in new behavior
• Elicit self-motivational statements
• Provide no unsolicited advice
• Roll with resistance
• Support self-efficacy
Approach in Practice
• Collaborative agenda setting—ensures patients and their families are active,
willing participants
o Asking permission ensures patient and family engagement
o Use open-ended questions—starts conversation moving
o Listen reflectively—keeps conversation moving, verifies understanding
• Decisions and goals—only patient and their family can decide to change
• Elicit change talk—explore interest, confidence, and readiness to change
• Exchange information—have patient and family interpret information
provided

Source: Tyler & Horner, 2008

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Conclusion

With new screen technologies constantly being developed, childhood is

becoming increasingly enveloped into a digital world. Many research studies
have proven that excessive screen time is associated with increased health risks,
especially in early childhood where face-to-face human interaction is crucial for
language development. Members of the American Academy of Pediatrics
have been releasing policy statements concerning the effects of children’s
media use since 1984 when the Task Force for Children and Television was
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

created. Despite increasing opportunities for screen time and evidence on the
risks of too much screen time, an astounding 84% of primary care providers do
not advocate for screen time reduction during clinic visits. This may partially
explain why a majority of young children watch 4-5 hours of TV daily; their
caregivers may not know the risks involved.
The most important immediate action is to increase the number of
providers who give screen time education to patients and their families.
Knowledge empowers change. This toolkit provides the education that providers
need to be knowledgeable as well as confident in their ability to discuss screen
time with families. The 2-QAST is simple, easy to remember, and applies to all
patients. The algorithm guides providers to additional resources they can use to
refer their patients to community services. The patient education handouts
make the information more accessible in an organized and easy-to-follow
format. Being consistent about providing a few minutes of screen time
education at every wellness visit from 2-months-old to 5-years-old sets a solid
foundation for parents and children to create healthier screen time habits at
home. A delay in language development is only one of the many
developmental, physical, and psychosocial adverse effects associated with
excessive screen time. This toolkit serves as a foundational resource to be
expanded and enhanced in the future.

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Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Actions for
Primary Care Providers:
2-QAST

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 62

2-QAST
1. How much screen time does your child
consume daily?
2. Is there a TV or mobile media device
(tablet/iPad, cell phone, computer) in
your child’s bedroom?
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Motivational Interviewing Resources

UMass Med

http://www.umassmed.edu/cipc/motivational-interviewing/overview/

The University of Massachusetts Medical School offers online Motivational

Interviewing (MI) training from beginner to expert level. They offer CEs, a
Certificate of Intensive Training in Motivational Interviewing, and opportunities
for individual coaching.

MINT
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

http://www.motivationalinterviewing.org

The Motivational Interviewing Network of Trainers (MINT) is an organization that

promotes MI and offers resources for training and practice.

http://www.motivationalinterviewing.org/list-events

The events calendar lists dates and locations of live MI training courses to
include locations in NC (Asheville, Carrboro, Charlotte, Greensboro):

Book List: http://www.motivationalinterviewing.org/books

Multimedia Resources: http://www.motivationalinterviewing.org/multimedia

CCNC

https://www.communitycarenc.org/media/files/mi-guide.pdf

Community Care of North Carolina developed a MI Resource Guide that offers

excellent tools for practicing MI techniques in clinical practice.

https://vimeo.com/135867754

Free 1-hr webinar hosted by Dr. Chip Watkins from the Carolinas Center for
Medical Excellence, produced in 2015.

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Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017 64

Article:
Family-Centered
Collaborative Negotiation
(Tyler & Horner, 2008)

`
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P R ACT I C E

Family-centered collaborative negotiation: A model for facilitating

behavior change in primary care
Diane O. Tyler, PhD, RN, FNP (Professor of Clinical Nursing) & Sharon D. Horner, PhD, RN (Professor)
School of Nursing, University of Texas at Austin, Austin, Texas

Keywords Abstract
Behavior change; family-centered
intervention; child health; primary care; Purpose: To describe a parent–child-based model that melds a family-centered
obesity. interaction approach, Touchpoints, with brief negotiation strategies (an adap-
tation of motivational interviewing) to address health risks in children. An
Correspondence application of the model for addressing childhood overweight in the primary
Diane Tyler, PhD, RN, FNP, School of Nursing, care setting is presented.
University of Texas at Austin, 1700 Red River
Data Sources: Selected research, theoretical, and clinical articles; national
Street, Austin, TX 78701.
recommendations and guidelines; and a clinical case.
Tel: (512)-471-9092; Fax: (512)-475-9179;
E-mail: [email protected] Conclusions: Lifestyle health behaviors are learned and reinforced within the
family; thus, changes to promote child health require family involvement.
Received: February 2007; Interventions that engage parents and support parent–child relationships, while
accepted: June 2007 enhancing motivation and the abilities to change behavior, are recommended.
Implications for Practice: Primary care is an appropriate setting for addressing
doi:10.1111/j.1745-7599.2007.00298.x lifestyle health behaviors. A collaborative partnership, rather than a prescriptive
manner, is advocated for primary care providers when working to facilitate
health-promoting behavior.

lifestyle behavior intervention; however, many report that

Introduction
they lack these skills (Jonides, Buschbacher, & Barlow,
Morbidity and mortality associated with typical lifestyles of 2002; O’Brien, Holubkov, & Reis, 2004). The purpose of
excessive dietary intake, low activity, inadequate sleep, this article is to describe a parent–child-based model that
and other poor health habits are impacting both quality melds a family-centered interaction approach, Touch-
of life and life expectancy, particularly among chil- points (Brazelton, 1992), with brief negotiation strategies
dren (Centers for Disease Control and Prevention to address health risks in children. An application of the
[CDC], National Center for Chronic Disease Prevention model for addressing overweight in children will be
and Health Promotion, 2005; Haslam & James, 2005; See, presented.
Mensah, & Olopade, 2006). It is projected that for the first
time in modern history, children will have more chronic
Background
diseases and reduced years of life than their parents
(Daniels, 2006; Olshansky et al., 2005; van Dam, Willet, Well-child visits are designed to facilitate the early
Manson, & Hu, 2006). The American Academy of Pediat- detection of health risks and emerging health problems
rics (2001) adopted policy statements that describe the (Cifuentes et al., 2005; Simonian, 2006). The primary
behavioral health problems of children as a ‘‘new morbid- care setting offers many benefits for managing lifestyle-
ity’’ and identified issues such as obesity, chronic stress, related health problems; in particular is the opportunity
divorce, single parenting, and depression as conditions for incorporating health promotion and prevention
that need to be addressed by primary care providers (PCPs) counseling into routine well-child and episodic sick
during routine healthcare visits. Thus, PCPs need skills for care visits. However, conventional health promotion
managing psychosocial concerns as well as approaches for and prevention approaches in primary care settings

194 Journal of the American Academy of Nurse Practitioners 20 (2008) 194–203 ª 2008 The Author(s)
Journal compilation ª 2008 American Academy of Nurse Practitioners
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D. Tyler & S. Horner Family-centered collaborative negotiation

generally involve a passive approach in which informa- Collaborative negotiation model

tion about health behaviors is delivered and supple-
The collaborative negotiation model describes a pro-
mental materials are offered to clients to facilitate
cess for promoting health and reducing health risk
their adherence to the clinician’s predetermined regi-
factors in primary care settings (Figure 1). The model
men (Glascoe, Oberklaid, Dworkin, & Trimm, 1998). In
contains three major constructs: (a) factors that affect the
essence, this is a top-down management model. The
child’s health and risk status, (b) a family-centered in-
effectiveness of such an approach is limited by the
tervention with the PCP to negotiate behavior change,
parents’ abilities to implement the clinicians’ plans
and (c) health indicators that reflect outcomes of the
and the resources available to support the parents as
PCP–family interaction.
they struggle with changing lifestyle behaviors (Ariza,
Greenberg, LeBailly, & Binns, 2005).
Child health profile
Although health promotion counseling can be initiated
by PCPs, the reality is that health promotion is a family af- Children’s health and risk status are influenced by
fair. The family is the context where ‘‘health is learned, lived, contextual and dynamic factors. Contextual factors repre-
experienced, and the niche where multiple members sent inherent biological conditions, such as the child’s
encounter and respond to disease and illness across the life genetic makeup, race and ethnicity, and personal and
course’’ (Denham, 2003, p. 145). The family provides the family health history. In regard to a person’s weight
resources to support health and make decisions about what status, a clear genetic predisposition for obesity has been
they believe to be health-promoting actions (Denham). To seen in studies of twins, other siblings, and family mem-
effect real lifestyle change in at-risk children, it is imperative bers, with the impact of genetic contribution estimated to
that family-based approaches be used. Yet, responses from be 30%–70% (Loos & Bouchard, 2003). While the child’s
PCPs indicate that many are not comfortable with parental genetic makeup establishes some limits on functioning, it
conflicts that arise during discussions about changing life- does not predetermine the child’s health outcomes. In
style behaviors such as those needed to manage child- fact, practice-based genetic counseling focuses on
hood overweight (Story et al., 2002). However, research increasing health promotion to counterbalance genetic
has shown that client-centered and nonconfrontational ap- influences (Nussbaum, McInnes, & Willard, 2004). For
proaches are effective in minimizing resistance to advice example, familial history of early cardiovascular disease
and in fostering relationships among clinicians and clients or type 2 diabetes is a strong genetic component, but
(Emmons & Rollnick, 2001). Additionally, the most con- lifestyle changes that promote weight management and
sistently successful family interventions have been inten- nutrition balance can help prevent or delay the onset of
sive programs involving frequent contact with behavioral these chronic conditions (Delahanty & Nathan, 2004;
specialists and inclusion of multiple controls and/or sup- Hamman et al., 2006; Hayman et al., 2004; Knowler
port components in the child’s environment (Epstein, et al., 2002).
Roemmich, & Raynor, 2001). Thus, adaptations are needed Race and ethnicity also have a profound impact on
for working with families in primary care settings. health. In the case of overweight, prevalence is twice the

Lifestyle Health Indicators:

Child Health Profile:
* Weight-related indicators
* Contextual Factors o Body mass index
o Genetics Parent Child
o Waist circumference
o Race/ethnicity * Exercise-related indicators
o Health history o Activity level
* Dynamic Influences o Fitness
o Family PCP o Cardiovascular
environment parameters
o Knowledge * Nutrition-related indicators
o Attitudes o Eating behaviors
o Metabolic parameters
Collaborative Negotiation * Sleep-related indicators
between Primary Care Provider (PCP) o Sleep latency
and Parent-Child Dyad o Sleep duration
* Quality of life

Figure 1 Family-centered collaborative negotiation model.

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Family-centered collaborative negotiation D. Tyler & S. Horner

rate among minorities, with 24% of Mexican Hispanic and to facilitate behavior change in a variety of settings
20% of African American children aged 6–11 years clas- and populations (Berg-Smith et al., 1999; Bernstein,
sified as overweight as compared to 12% of non-Hispanic Bernstein, & Levenson, 1997; Heather, Rollnick, Bell,
White children (Ogden, Flegal, Carroll, & Johnson, 2002). & Richmond, 1996; Marlatt et al., 1998; Miller, Andrews,
A review of nutrition-related research identified factors Wilbourne, & Bennett, 1998; Richmond, Heather,
that contributed to children’s overweight including lim- Kehoe, & Webster, 1995; Rollnick, Heather, Gold, &
ited food choices, lower access to affordable and quality Hall, 1992; Saunders, Wilkins, & Phillips, 1995; Senft,
foods, fewer family meals eaten together, and cultural food Polen, Freeborn, & Hollis, 1997; Trigwell, Grant, & House,
preferences that promote higher fat and salt consumption 1997).
(Jenkins & Horner, 2005).
Touchpoints model of care
Dynamic influences on lifestyle behaviors include the
family environment and parents’ and children’s knowl- The Touchpoints approach is based upon over three
edge and attitudes about health behaviors. Nader et al. decades of research and clinical practice by Brazelton,
(1996) found that family involvement increased child- a pediatrician who has both medical and psychoanalytic
ren’s knowledge and positively improved attitudes training. The model describes the predictable times in
toward healthy lifestyle behaviors. Additionally, when a child’s development, characterized by spurts of growth
family meals are a regular event, this becomes an impor- and trying periods of regression, that often disrupt the
tant ritual in which parents communicate about family child’s life but also can result in disorganization and stress
culture, traditions, and values (Mendoza & Fuentes- in the family unit. Brazelton’s early work with mothers
Afflick, 1999). Beliefs about what is healthful or and infants demonstrated that when practitioners work as
unhealthy are communicated to children through the partners with parents to anticipate developmental or sit-
family conversations as well as actions and choices uational transitions, they could have a positive impact on
enacted by individual family members, and this serves the child’s growth and development. Consequently, chil-
to maintain the family’s cultural continuity (Mendelson, dren have better outcomes in physical, social, emotional,
2003). So that when a parent encourages a child to ‘‘eat and cognitive well-being (Brazelton, 1975a, 1975b, 1992).
your vegetables, they help keep you healthy’’; this is Brazelton’s work has been expanded to families with older
a powerful message for the child to hear and incorporate children (Brazelton & Sparrow, 2001) and has been imple-
into his or her own belief systems (Brown & Ogden, mented in over 70 sites (Brazelton Touchpoints Center,
2004). 2007; Brazelton, O’Brien, & Brandt, 1997; Percy, Stadlter,
Practitioners who address the impact of the family envi- & Sands, 2002) and tested with different populations
ronment on children’s health can also make meaningful (Percy & McIntyre, 2001; Tyler, 2007). The guiding prin-
differences in lifestyle behaviors. This is substantiated by ciples and assumptions of the Touchpoints approach are
controlled randomized trials that demonstrated that early presented in Table 1.
intervention and family-based behavioral approaches to Touchpoints differs from the traditional ‘‘problem-
weight management led to long-term weight loss in chil- oriented’’ healthcare model in that it is a strength-based,
dren (Connelly, Gargiula, & Reeve, 2002; Epstein, Myers, as opposed to a deficit-based, model. In the traditional
Raynor, & Saelens, 1998; Golan, Weizman, Apter, & model, the healthcare provider assumes the expert role,
Fainer, 1998). The landmark study by Epstein, Valoski, whereas the Touchpoints model shifts away from the
Wing, and McCurley (1990, 1994) with a 10-year follow- objective prescriptive approach to a more empathetic
up demonstrated that interventions targeting parent– and collaborative partnership. For example, recogniz-
child versus child-only or no–specific family member ing and valuing the positive influences that the parent
target were more effective in long-term weight loss and has in care of the child bring the practitioner–parent–
maintenance. child together in care and support of the child and
family, providing parents and children a sense of mastery
or the belief in their capacity to master health promotion
Collaborative negotiation process
of a complex health problem (Brazelton & Sparrow,
Family-centered collaborative negotiation focuses on 2003).
health concerns that are defined through PCP–family The Touchpoints model provides a framework for apply-
discussions; strategies are then identified and adapted to ing behavioral change strategies with families. It is not
fit the child’s unique contextual and dynamic makeup. a program or set of skills to be applied by practitioners but
The collaborative negotiation process combines the enhances programs and service delivery systems by adapt-
Touchpoints approach (Brazelton, 1992) with the brief ing to the unique and diverse forces present in the family
motivational interviewing approach that has been used and individual practitioner.

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D. Tyler & S. Horner Family-centered collaborative negotiation

Table 1 The guiding principles and assumptions of the Touchpoints Table 2 Brief negotiation principles and approach
model
Principles
Principles Be client centered
Value and understand the relationship between you Establish a partnership with client
(i.e., PCP) and the parent Develop discrepancy between current behavior and lifestyle goals
Use the behavior of the child as your (PCP) language Explore and resolve ambivalence about engaging in new behavior
Value passion where ever you (PCP) find it Elicit self-motivational statements
Focus on the parent–child relationship Provide no unsolicited advice
Value disorganization Roll with resistance
Look for opportunities to support mastery Support self-efficacy
Recognize the beliefs and biases that you (PCP) bring to Approach in practice
the interaction l Collaborative agenda setting—ensures clients are active,

Be willing to discuss matters that go beyond your (PCP) willing participants

traditional role Asking permission—ensures continued client engagement
Assumptions about parents Use open-ended questions—starts conversation moving
The parent is the expert on his or her child Listen reflectively—keeps conversation moving, verifies
All parents have strengths understanding
All parents want to do well by their child l Decisions and goals—only the client can decide to make change

All parents have something critical to share at each l Elicit change talk—explore interest, confidence, and readiness

developmental stage to change

All parents have ambivalent feelings l Exchange information—have client interpret information

Parenting is a process built on trial and error provided

Assumptions about practitioners
Each practitioner is the expert within the context of his or
her practice setting
setting targets, (c) assessing motivation and confidence
Practitioners want to be competent regarding the planned actions, and (d) exchanging infor-
Practitioners need to reflect on their contribution to mation (Rollnick, 1996). The essence or ‘‘spirit’’ of the
parent–provider interactions method is a quiet and eliciting interpersonal counseling
PCP, primary care provider.
style, where the therapeutic relationship functions as
a partnership rather than as an expert–recipient relation-
ship (Emmons & Rollnick, 2001).
Brief negotiation approach
Brief motivational interviewing methods fit well with the
This method is an adaptation of motivational interview- Touchpoints model, and the negotiated process incorporates
ing (MI), which is a therapeutic technique that can be principles from both approaches to work with individuals in
effective at increasing clients’ motivation, or readiness, to collaboration with family members to engage in behavior
change problem health behaviors (Miller & Rollnick, change. The collaborative negotiation intervention is deliv-
2002). The basic components of MI are development of ered in the manner of having a dialogue or shared discussion
the clients’ discrepancy between present behaviors and about the health concerns of the family member(s). As
future goals, reduction of client resistance and ambiva- concerns (i.e., weight, disordered eating, and inactivity)
lence to making changes, use of reflective and empathic are explored and contributing risk behaviors are identified,
listening, and the reinforcement of self-motivational state- the PCP employs strategies designed to elicit motivation to
ments from the client. Originally, it was adapted from change from the parent and child. If a decision for a planned
Miller’s (1983) work in the addictions field where straight- change is agreed upon, specific actions for change and
forward advice giving was met with resistance and argu- confidence in their ability to enact the plan are discussed.
ments against change. During this exchange, supports and constraints are
The components of MI have been incorporated into explored, as well as the anticipated effect of the planned
a brief format by practitioners for use in healthcare settings change on family routines and individuals in the family. A
to encourage health promotion and lifestyle behavior key goal of the approach is to have parents and their children
change during routine consultations with patients become active participants throughout the interaction, from
(Table 2). Strategies and techniques used in this approach identifying the behavior to change, sharing of information,
are referred to as ‘‘brief negotiations’’ because each strategy to making the plan for attaining the desired health outcome.
is designed to take 5–15 min to complete and the patient,
not the practitioner, articulates what actions she or he will
Lifestyle health indicators
undertake (Rollnick, Heather, & Bell, 1992). Negotiation-
based strategies involve four fundamental tasks: (a) setting Health behaviors can impact multiple health outcomes.
a mutually agreeable agenda, (b) making decisions and For example, engaging in regular vigorous physical

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Family-centered collaborative negotiation D. Tyler & S. Horner

activity improves weight management, cardiovascular with adverse health outcomes. There has been a consistent
functioning, bone density, glucose uptake by muscles, positive association found between the number of hours
sleep quality, and energy level and can reduce risk and children watch television and the prevalence (Andersen,
reverse atherosclerosis (Daniels, 2006; Pate et al., 2006). Crespo, Bartlett, Cheskin, & Pratt, 1998; Crespo et al.,
Lifestyle health indicators can be sorted into categories that 2001) and degree (Gortmaker et al., 1996; Robinson,
reflect the parent’s and child’s primary area of concern 1999) of overweight. Children between the ages of 8
such as weight, exercise, nutrition, sleep, or overall quality and 13 watch television an average of 3.5 h a day (Roberts,
of life (Figure 1). Foehr, Rideout, & Brodie, 1999). In a longitudinal study of
school-age girls, Davison, Marshall, and Birch (2006)
Weight-related health indicators
found that being overweight at age 11 was 13 times more
Systematic reviews (Jain, 2004; Reilly et al., 2003) likely to occur among those girls who exceeded the rec-
report associations between childhood overweight as de- ommended hours of television viewing between ages 7
fined by body mass index (BMI) at the 95th percentile or and 11 than among girls who did not exceed recommen-
more for age and gender and cardiovascular risk factors, ded viewing times. Those of lower socioeconomic status
such as hypertension, dyslipidemia, hyperinsulinemia, and those who are Hispanic and African American watch
insulin resistance, and left ventricular and endothelial more television than do children of higher socioeconomic
abnormalities. More than half of overweight children aged families and those who are White, respectively (Crespo
5–10 years were found to have at least one cardiovascular et al.; Gortmaker et al.; Robinson, 1999, 2001). However,
risk factor. Increased waist circumference also correlates children watch less television if they have parents who
with a cardiovascular risk profile (Higgins, Gower, Hunter, watch less television themselves and monitor children’s
& Goran, 2001). Other physical consequences of over- television viewing (Woodward & Gradina, 2000).
weight are diabetes (types 1 and 2), asthma, polycystic
Nutrition-related health indicators
ovary syndrome, and orthopedic, hepatic, and sleep dis-
orders (Jain; Reilly et al.). Research on child nutrition and weight management is
Factors that contribute to weight problems can be attrib- limited. While calorie-restrictive diets are not indicated for
uted to genetic influences in terms of patterns of familial most overweight children because of potential effects on
overweight (Agras, Hammer, McNicholas, & Kraemer, long-term linear growth (American Dietetic Association
2004) and lifestyle factors such as activity levels and [ADA] Reports, 2004; Epstein et al., 1994), dietary changes
nutrient intake (Chaput, Brunet, & Tremblay, 2006). that decrease calorie-dense foods and increase fruits and
Identification of risk factors can assist PCPs to identify vegetables or nutrient-dense foods are advocated (ADA
children who need targeted interventions to prevent the Reports; CDC, n.d.). Dietary guidelines that recommend
numerous physical and psychological health problems consumption of five to nine servings of fruits and vegeta-
that are attributed to childhood overweight (Agras et al.; bles daily are based on substantial scientific evidence that
Chaput et al.; Cohen, Tallia, Crabtree, & Young, 2005). addresses the quality of these foods as good sources of
nutrients and their association with decreased cancer,
Exercise-related health indicators
cardiovascular disease, and hypertension in adults (CDC,
Numerous reports of studies with adults demonstrate n.d.). Diets high in fruits and vegetables are thought to
that increased physical activity substantially improves aid in weight management by promoting satiety because
health outcomes, such as obesity, cardiovascular risk fac- of increased water and fiber content and through de-
tors and disease, diabetes, hypertension, blood lipid dis- creased fat content and energy density. In a review of
orders, cancer, arthritis, and depression (U.S. Department behavioral interventions to modify dietary fruit, fat, and
of Health and Human Services, 1996). In contrast, there vegetable intake, Ammerman, Lindquist, Lohr, and
are limited studies of exercise or physical activity benefits Hersey (2002) found that goal setting increased average
that have been conducted with children. In Epstein et al.’s daily servings by 0.6. Use of theory-based interventions
(1994, 1998) 10-year longitudinal study, findings indicate has also been found more effective in achieving positive
that flexible lifestyle exercise may be superior to more dietary outcomes than nontheoretically based studies
structured and higher intensity aerobic exercise for weight (Agency for Healthcare Research and Quality, 2000).
control. For children, the U.S. guidelines recommend
Sleep-related health indicators
60 min of moderate-to-vigorous physical activity daily,
which can be accumulated throughout the day (Corbin & Sleep is integral to human functioning in that restorative
Pangrazi, 1998). processes occur during sleep states (Liu, Liu, Owens, &
Many studies have focused on the lack of exercise or Kaplan, 2005). Research with adults has identified link-
increased sedentary activity of children and associations ages between sleep deficits and changes in carbohydrate

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D. Tyler & S. Horner Family-centered collaborative negotiation

Table 3 Case example of the collaborative negotiation process

Family–PCP interaction Brief negotiation Touchpoints

PCP: I see that Augie’s weight and height were taken today and her weight is Exchange information
above normal. Her blood pressure is also higher than it should be.
Parent: Oh, really. Well, she is like her father’s side of the family.
PCP: So, she is like others in your husband’s family. Simple reflection: restating
Parent: Yes, most of them are short and heavy.
PCP: In addition to be being too heavy or overweight, who has high Open question
blood pressure, diabetes, high cholesterol, or heart disease
in either his or your family?
Parent: I know my mother-in-law has diabetes. Some aunts and uncles also
have diabetes and some other problems, too.
PCP: So, being heavy and having health problems, like diabetes, are Simple reflection:
in the family. summarizing
Parent: Yes. I tell Augie to do something besides watch TV, like go outside and
play.
PCP: Sounds like you’ve been concerned about her not getting enough activity Complex reflection: Parent desires to do well by
and maybe concerned about her weight, too. interpreting the child
Parent: (nods)
PCP: You’ve encouraged her to be more active. That can be helpful, because Support by affirmation; Support mastery; value
being too big, weighing too much, can cause many health problems mutual agenda setting; and understand the
like diabetes and high blood pressure. I’ll be giving Augie an examination asking permission PCP–parent relationship
today, and I’d like to spend a little time to talk with
you both about a healthy weight. Is that okay with you?
(Both parent and Augie nod)
PCP: Augie, tell me some of the things you like to do.
Child: I don’t know, watch TV, be on the computer, ride my bike sometimes. PCP interprets derogative
Parent: Yeah, she’s really a couch potato. language as ‘‘passion’’
PCP: (To Augie) Okay, sometimes bike riding, but mom is concerned about the Reflections: restating and
time sitting at the computer and watching TV. reframing
PCP: Tell me what a typical day is like at home. Seek to understand the P-C
Parent: Things are pretty bad right now. My husband and I are separated. Complex reflection: relationship
interpreting
PCP: That sounds stressful.
Parent: Yeah. I’ve been going back to school in the evening. And my husband’s
not paying any child support.
PCP: It’s good that you were able to bring Augie to the clinic today with Support by affirmation; Focus on strengths; support
all that’s going on. How are you managing the children, work, and school? open-ended question mastery
Parent: My in-laws live close by; they help out. Augie and my son stay with
them until I get home. Augie watches the novellas with her
grandmother and they drink sodas. too many sodas. I don’t buy
them, unless we have company.
PCP: So, Augie, your mother doesn’t usually buy sodas, but you drink them Simple reflection: Focus on child’s behavior
at grandma’s house. (She nods.) How many sodas do you usually summarizing
have in a day?
Child: (shrugs shoulders)
PCP: more than 2 or 3 a day?
Child: (she nods)
PCP: So most days you’re at grandmother’s, watch TV, and have more than
3 sodas. (Both nod, yes.)
PCP: Are they diet sodas?
Parent: No
PCP: And this is the grandmother with diabetes. State discrepancy between Value passion, negative
Parent: Yes, she is overweight, too. Her husband is always on her about what behaviors and goals; responses may result from
she eats, especially her Cokes. reflection, reframing; true concern; foster
PCP: Sounds like your grandpa wants to keep her healthy. Augie, just like your client centered; setting parent–child–PCP
mother and I want to help you. agenda; eliciting relationship
I have here a list of recommendations to help families have healthy motivation and change
lifestyles. We can talk about each one of these and I can tell you what talk
other families have tried, but I’m interested in hearing what you think will
work for you and Augie and others in the family.

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Table 3 Continued

Family–PCP interaction Brief negotiation Touchpoints

P-C: (They review the following list, which has colorful cartoon icons for Making decisions and setting
each topic.) targets
l Increase physical activity—at least one hour/day

l Decrease TV/screen time—less than 2 hours/day

l Drink 6–8 glasses water/day and only 1 cup of sugar drink/day

l Eat 5–7 fruits and vegetables/day

l Eat breakfast daily

l Limit portion sizes

PCP: Making changes in each of these areas can improve health over a period of
time. Which change would be something that you could work on?
Parent: Increasing activity, decreasing TV and less soda, all would help, but
realistically right now I think getting her to stop drinking sodas would
make a big difference.
PCP: Augie, how does that sound to you?
Child: (Looks down and shrugs shoulders) Roll with resistance Acknowledge the disruption
(disorganization) that this
change will evoke
PCP: This will be a big change for her. and for the grandmother. How can we
get the grandparents, especially grandma, to help with this?
Parent: I’ll just tell her that they need to quit letting Augie have the sodas.
PCP: How is your relationship with the in-laws? Open-ended question
Parent: Usually pretty good, especially lately, with all that is going on at home.
PCP: Okay. I’m going to ask you both some questions. (To parent) On a scale Eliciting change talk;
from 0 to 10, with 0 being ‘‘not important at all’’ to 10 being ‘‘very exploring motivation
important,’’ how important do you think it is for Augie to have no more
than 1 cup of soda a day?
Parent: 10
PCP: Okay, so you think it is very important. Now, how confident are you that you
will be able to help her and grandma to make this change, with 0 being ‘‘not
confident at all’’ and 10 being ‘‘you feel very confident’’ that they can stop
drinking the sodas.
Parent: Maybe 6 or 7.
PCP: Okay, that’s great. Now tell me why did you say 6 or 7 instead of something Exploring barriers
higher like an 8?
Parent: Well Augie cries when she does not get what she wants sometimes and
her grandmother will give in to her.
PCP: What do you think will help grandmother to not ‘‘give in?’’
Parent: I’m going to tell her that her doctor said she is too big and she needs to
stop drinking sodas or she will get diabetes like her.
PCP: That could work. Many times parents are able to make healthy changes for Providing affirmation
someone else, like for their child, or grandchild, when they may not be
motivated to make the change for themselves.
PCP: (Augie is asked the ‘‘How important’’ and ‘‘How able’’ questions. She shrugs Roll with resistance (change
her shoulders and although she has direct eye contact with the PCP, she approach)
does not provide verbal responses.) Augie, if you could have one small
serving of soda a day or one juice drink a day, what would you choose, the
juice or soda?
(The PCP continues by sharing information about offering healthy Support self-efficacy; Foster PCP–parent
alternatives and being consistent with Augie, which will help reinforce partnership with parent relationship
the target behavior. Support and encouragement are provided to
enhance efficacy for both parent and child. For example, stating that
strategies, such as these have worked for others and that the PCP is
confident they that will find ways to be successful and then asks that they
return in a few weeks to discuss how their plan is working. The PCP
suggests inviting the grandparents to the next visit. Written information
containing recommendations and strategies for healthy eating and
activity is also provided.)

Note. P-C, parent–child; PCP, primary care provider.

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D. Tyler & S. Horner Family-centered collaborative negotiation

metabolism. Knutson (2005) analyzed data collected as lifestyle behaviors and thereby reduce health risks and
part of the National Longitudinal Study of Adolescent prevent health problems (Cifuentes et al., 2005; Puczynski
Health (Add Health) to determine associations between et al., 2005). Interventions that rely solely on advice giving
sleep duration and BMI in adolescents who were in grades most often do not substantially effect lifestyle changes and
7–12. Findings indicated that sleep deficit was associated improve health, and they are frequently met with resis-
with overweight BMI for male adolescents such that for tance from clients. The collaborative negotiation approach
every hour of additional sleep, the adolescents would have differs from the traditional prescriptive approach in which
10% reduction in the risk for being overweight. Similarly the management plan is determined by the healthcare
in a study with 422 randomly selected school-age Cana- provider. The negotiated process incorporates principles
dian children, Chaput et al. (2006) found that sleep dura- from well-established clinical approaches to work with
tion was negatively associated with children’s BMI and individuals in collaboration with family members to
waist circumferences. Tzischinsky and Latzer (2006) stud- engage in behavior change. Touchpoints, well known in
ied sleep quality and duration in overweight and normal- pediatric settings, enhances and strengthens the relation-
weight children and found that overweight children ships among parents, children, and the healthcare pro-
reported significantly more nighttime awakenings, snor- vider. Brief motivational interviewing methods in primary
ing, and restless sleep than did normal-weight children. care settings have been found effective in helping individ-
uals manage a variety of lifestyle behavioral health con-
Quality of life
cerns. Furthermore, clinical populations have responded
Health-related quality of life can be negatively impacted well to the patient-centered approach in which healthcare
when children experience frequent or increasing symp- providers work with them to gain confidence and mastery
tomatic episodes of chronic or recurrent health problems, in behavior change.
when they are unable to participate in age-appropriate Time to develop skills and gain competence using brief
activities, and when their self-esteem or self-worth is negotiation strategies varies among providers; however,
lowered (Laforest et al., 2005; Obradovic, van Dulmen, many PCPs, particularly those with a nursing background,
Yates, Carlson, & Egeland, 2006). For example, children will view this approach as similar to methods associated
with chronic health problems like asthma or diabetes can with establishing rapport, ensuring a trusting therapeutic
experience symptom exacerbations that limit their daily relationship, and developing a health plan based on
activities and reduce their quality of life (Sawyer et al., mutual goals. Little to no research, however, has been
2005). Overweight children can experience lower self- conducted using brief negotiation or motivational inter-
esteem that reduces their quality of life (Fallon et al., viewing with parent–child dyads. With the behavioral
2005). Participating in exercise and feeling confident in health concerns of today’s youth, the collaborative ap-
one’s abilities to engage in physical activity have associated proach warrants investigation with this population and
psychological benefits (Kim, 2004). in a variety of healthcare settings.

Acknowledgments
Application of the collaborative negotiation
model: Overweight child Development of this article was supported by NIH/NIRN
R21 NR09853, Primary care of families with overweight chil-
Current estimates of childhood obesity indicate that one
dren, 9/13/2005-7/31/2007. The authors would like to
in three school-age children is either overweight or at risk
recognize and thank Cathy Cole, MSW, cathycoletraining,
for overweight (National Center for Health Statistics,
inc, Motivational Interviewing Network of Trainers, for
2004). With the high prevalence of obesity in the United
her review of the motivational interviewing and brief
States, it is imperative that PCPs intervene with families
negotiation content.
at every opportunity to prevent and manage this health
concern. A sample PCP–family interaction illustrating the
collaborative negotiation is presented in Table 3 using the
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Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Patient Education:
BROCHURE
(print double-sided)

31 Click here for Algorithm

Click here for Table of Contents
 76

LESS
- IS -
MORE
Additional
Health Risks Useful
Too much screen time
Websites
can also lead to… Find age-appropriate high-
quality media from over
• Obesity
20,000 listings:
• Violence and www.commonsensemedia.org
Create a Family Media Use
aggression Plan with AAP’s interactive
online tool:
• Loss of social skills
www.healthychildren.org/
• Attention problems mediauseplan
Learn more about the annual
• Anxiety and Screen-Free Week and
Children’s Book Week at:
depression
www.screenfree.org
• Sleep deprivation Go to AAP’s Media and Parent Strategies to
Children Communication
• Vision problems Toolkit for more tips: Reduce Screen Time
www.aap.org/en-us/advocacy- for Children Younger
• Migraine headaches and-policy/aap-health- Than 6-Years-Old
initiatives/pages/media-and-
• Repetitive motion children.aspx š›
syndrome Based on recommendations by

• Arthritis
š› the American Academy of
Pediatrics
© 2017 Cristina Kuta
1
2

77

Quick Tips

þ Read daily to your

child for at least 20
minutes in an interactive
way (pointing to pictures,
asking questions)

þ No screen time for

children younger than
18-24 months, except
video chatting
Prevent language delays – Reduce screen time!
þ Up to 1 hour per day
Human interaction has a strong 3 to 5 times more likely to develop a high-quality screen time
influence on language development. language delay. If children watch television for children ages 2 to 5
Language development and vocabulary and videos alone, their risk doubles.
growth in young children are directly related The American Academy of Pediatrics þ Create a Family
to the amount of time parents spend (AAP) recommends no screen time for Media Use Plan
speaking to them. Too much screen time can children under 18 to 24 months and a
interfere with language development because maximum of 1 hour per day of high-quality þ View and use media
parents spend less time interacting with and screen time for children ages 2 to 5 because with your children
talking to their child. Also, children who have of the potential harm it could have on the
certain types of language delays by age 5 are developing brain. The AAP’s website features þ Make family meal
at risk for social and emotional problems in
an interactive tool to create your own Family times screen-free
adulthood.
Media Use Plan and learn how to decrease
About 1 in 4 American children are
screen time in your home. Be creative and þ No screen time 1
exposed to an average of 4 hours of screen
schedule a screen-free week for your family hour before bedtime
time every day. Research shows that for
every 1 hour of television watched, children or celebrate National Screen-Free Week and
hear 500 to 1000 fewer words. Also, young Children’s Book Week in April/May. Give your þ No TVs or media
children who are regularly exposed to more children the best chance to develop their
devices in the bedroom
than 2 hours of screen time per day are language skills in a healthy and natural way!
 78

Patient Education:
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

POSTER

`
34 Click here for Algorithm
Click here for Table of Contents
 79

P e ent Lang age De ays - Reduce Sc een

· tes · an � teract e
pie res, as g q es �ons

__Q sc ee e for ctu dren younger than

18-2 o ths except video chatting

UP TO 1 HOUR PER DAY high-quality

sc ee t,me for childen ages 2 to 5
o Go to www commonsensemedia.org for
age-appropriate, quality media options

v�ew and use media WITH your children

Make family meal times TECH-FREE

NO screen time 1 hour before bedtime

v NO TVs or media devices in the be@

© 2017 Cristina Kuta
 80
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Patient Education:
FAMILY MEDIA
USE PLAN

`
36 Click here for Algorithm
Click here for Table of Contents
 Family Media Use Plan 81

For children younger than 6-years-old

This media plan was developed by the American Academy of Pediatrics (AAP) and is appropriate for
children younger than 6-years-old. The interactive Web version for children of all ages is available at:
www.healthychildren.org/English/media/Pages/default.aspx#wizard

Screen Free Zones

Mobile devices & TVs are not allowed in the following screen-free zones
in our home:
þ Kitchen or dining room table
• Keep family mealtimes & other family & social gatherings tech-free.

þ Bedroom
Recharge devices overnight - outside your child's bedroom
• incoming messages & calls can interfere with your child's sleep
• help children avoid the temptation to use or check devices when they should be sleeping
• emitted light from devices charging may still effect the quality of your child's sleep

þ Stroller

Screen Free Times

The AAP recommends no screen time for children under 18-24 months, except for video
chatting. For children ages 2 to 5, limit screen time to less than 1 hour per day of quality
programming or gaming.

As part of the daily routine, make devices like TVs, phones, computers, games or other electronics off
limits at specific times. Dinnertime & before bedtime are important ones, but more extended breaks
from technology each day may also be needed, especially for families with very young children.

We will not use mobile devices or other screens during the following
times:
þ One hour before bed
Using a mobile device or watching TV before bed can interfere with a child's sleep. When using
screens in the evening:
• Turn the brightness on the screen down
• Don't play or watch media that are intense or scary in the evening

þ Meal times
Do not watch TV or use mobile devices at meal times.
 • It is associated with obesity & weight gain in children. 82
• It discourages from family interaction.

þ Family time
• Family time may be whenever the family is together or it may be during specific times such
as when in the car together or when walking to school together.

þ While in the car, except for long trips

Choose & Diversify Your Media

Choose Media that is Worth Your Time:
More than 80,000 apps are labeled as educational, but little research has demonstrated their actual
quality. Products pitched as "interactive" should require more than "pushing & swiping." Look to
organizations like Common Sense Media (www.commonsensemedia.org) for reviews about age-
appropriate apps, games & programs to guide you in making the best choices for your children.

Diversify Your Media:

Use media in a way that promotes interaction, connection & creativity. Different types of media may
each have potential benefits, so media use is best diversified so that not all of one's time is spent doing
one particular activity.

When we have recreational screen time, we will:

þ Co-view (watching media with a parent or adult)
• Co-viewing allows for interaction & discussion
• Younger children learn better from media, educational shows & videos when they are co-
viewed & there is parent-child interaction.

þ Co-play (playing video games & using apps with a parent or adult)
• Younger children learn better from media when they share the experience with an adult.
• Helps parents to stay connected with their children & teens.
• Allows parents to have better sense of how their child is spending his or her time.

þ Watch "educational" shows & use apps that have been reviewed & vetted by trusted sources to
actually be educational such a PBS or Common Sense Media

þ Use media to connect me to others

• Video chat with friends or relatives

þ Use media to be creative

• Use apps & play games that let me use my creativity

þ Limit background media

• This is distracting to me & limits the "talk time" I have with adults

þ NOT spend lots of time watching fast-paced shows or apps with lots of bells & whistles
• These types of shows & apps may affect brain development & make it harder for children to
concentrate later in life.
 83
þ NOT use media as a babysitter

þ NOT play video games that are against our family’s rules both at home & at someone else’s house

þ NOT download apps, movies, games without permission & asking an adult if they are appropriate
for my age

þ NOT visit new websites or video sites without asking permission

Balancing Online & Off-line Time

Media & digital devices are an integral part of our world today. The benefits of these devices, if used
moderately & appropriately, can be great. But research has shown that face-to-face time with family,
friends & teachers, plays a pivotal & even more important role in promoting children's learning &
healthy development. Keep the face-to-face up front & don't let it get lost behind a stream of media &
technology.

By decreasing screen time, we will have more time for:

þ Playing outside

þ Looking at books, going to the library

þ Playing dress-up or make believe

þ Playing with friends

þ Being with my family

þ Playing with blocks, Legos & puzzles

Sleep & Exercise

All children need plenty of sleep & exercise each day. On average, children younger than 6-years-old
require 10-14 hours of sleep (including naps).

We will get enough sleep & exercise by doing the following:

þ Turn off the TV or mobile device one hour before bedtime

þ The blue light from the TV or mobile screen can interfere with sleep

þ Vibrating & audio alerts can wake children from sleep

þ Children may wake up to use devices in the middle of the night or early in the morning
 84
Websites For Families

Common Sense Media

http://www.commonsensemedia.org
Search for age-appropriate high-quality media including movies, games, apps,
websites, TV shows, books, and music from over 20,000 listings

PBS Kids
http://pbskids.org
Quality educational media content
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

American Academy of Pediatrics

http://www.healthychildren.org/mediauseplan
Create a Family Media Use Plan with AAP’s interactive online tool

Campaign for a Commercial-Free Childhood

http://www.screenfree.org
Learn more about the annual Screen-Free Week and Children’s Book Week

Talk with Me Baby

http://www.talkwithmebaby.org
Parenting ideas

Talking is Teaching: Talk, Read, Sing

http://talkingisteaching.org
Fun tips and resources to building language and literacy skills

Zero To Three
http://www.zerotothree.org
Play-based ideas to stimulate child development

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 85
Child Development Community Resources for
Wayne County, NC

Child Development Community Resources for Wayne County, NC

http://www.dpi.state.nc.us/docs/earlylearning/2013foundations-color.pdf
North Carolina Foundations Task Force: North Carolina Foundations for Early
Learning and Development (2013) – referred to as Foundations. Provides age-
appropriate goals and developmental indicators for infants, toddler, and
preschoolers for both caregivers clinicians. Language development and
communication is covered on pages 88-115 of the guide.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

North Carolina Infant-Toddler Program

http://www.beearly.nc.gov
Serves families with children up to 3-years-old with special needs.

Wayne County, NC – Community Resources for Children

http://www.waynegov.com/DocumentCenter/Home/View/291
Children and Youth with Special Health Care Needs
Wayne County Resource Guide, published in 2012

North Carolina Pre-K Program

http://ncchildcare.dhhs.state.nc.us/general/mb_ncprek.asp

Partnership for Children of Wayne County, NC: Pre-K Program

http://pfcw.org/for-parents/nc-pre-k-for-parents/

List of Pre-K Programs in Wayne County, NC

http://www.pfcw.org/wp-content/uploads/NC-Pre-K-Site-Addresses.pdf

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Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

American Academy of
Pediatrics:
2016 Policy Statement
Media and Young Minds

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 87

POLICY STATEMENT Organizational Principles to Guide and Define the Child Health
Care System and/or Improve the Health of all Children

Media and Young Minds

COUNCIL ON COMMUNICATIONS AND MEDIA

Infants, toddlers, and preschoolers are now growing up in environments abstract

saturated with a variety of traditional and new technologies, which they
are adopting at increasing rates. Although there has been much hope
for the educational potential of interactive media for young children,
accompanied by fears about their overuse during this crucial period of rapid
brain development, research in this area still remains limited. This policy
statement reviews the existing literature on television, videos, and mobile/
interactive technologies; their potential for educational benefit; and related
health concerns for young children (0 to 5 years of age). The statement also This document is copyrighted and is property of the American
highlights areas in which pediatric providers can offer specific guidance Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy
to families in managing their young children’s media use, not only in terms of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
of content or time limits, but also emphasizing the importance of parent– Pediatrics has neither solicited nor accepted any commercial
child shared media use and allowing the child time to take part in other involvement in the development of the content of this publication.

developmentally healthy activities. Policy statements from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, policy statements from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
organizations or government agencies that they represent.

INTRODUCTION The guidance in this statement does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
Technologic innovation has transformed media and its role in the lives into account individual circumstances, may be appropriate.
of infants and young children. More children, even in economically All policy statements from the American Academy of Pediatrics
challenged households, are using newer digital technologies, such automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
as interactive and mobile media, on a daily basis1 and continue to be
the target of intense marketing.2 This policy statement addresses the DOI: 10.1542/peds.2016-2591

influence of media on the health and development of children from 0 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
to 5 years of age, a time of critical brain development, building secure Copyright © 2016 by the American Academy of Pediatrics
relationships, and establishing health behaviors.
FINANCIAL DISCLOSURE: The authors have indicated they do
not have a financial relationship relevant to this article to
disclose.
INFANTS AND TODDLERS
FUNDING: No external funding.
Children younger than 2 years need hands-on exploration and social
interaction with trusted caregivers to develop their cognitive, language, POTENTIAL CONFLICT OF INTEREST: The authors have
indicated they have no potential conflicts of interest to
motor, and social-emotional skills. Because of their immature symbolic, disclose.
memory, and attentional skills, infants and toddlers cannot learn from
traditional digital media as they do from interactions with caregivers,3
To cite: AAP COUNCIL ON COMMUNICATIONS AND MEDIA.
and they have difficulty transferring that knowledge to their
Media and Young Minds. Pediatrics. 2016;138(5):e20162591
3-dimensional experience.4 The chief factor that facilitates toddlers’

PEDIATRICS Volume 138, number 5, November 2016:e20162591 FROM THE AMERICAN ACADEMY OF PEDIATRICS
 88

learning from commercial media 5 years of age11,12 and continue studies have used a 2-hour cutoff
(starting around 15 months of age) to create programming that to examine obesity risk, a recent
is parents watching with them and addresses evolving child health and study of 2-year-olds found that BMI
reteaching the content.5,6 developmental needs (eg, obesity increased for every hour per week
prevention, resilience). Evaluations of media consumed.21 It is believed
The interactivity of touchscreens
of apps from Sesame Workshop and that exposure to food advertising22
enables applications (apps) to
the Public Broadcasting Service (PBS) and watching television while
identify when a child responds
also have shown efficacy in teaching eating (which diminishes attention
accurately and then tailor its
literacy skills to preschoolers.2 to satiety cues)23 drives these
responses, thereby supporting
Unfortunately, most apps parents associations.
children at their levels of
find under the “educational”
competence. Emerging evidence Sleep
category in app stores have no such
shows that at 24 months of age,
evidence of efficacy, target only rote Increased duration of media
children can learn words from live
academic skills, are not based on exposure and the presence of a
video-chatting with a responsive
established curricula, and use little television, computer, or mobile
adult7 or from an interactive
or no input from developmental device in the bedroom in early
touchscreen interface that scaffolds
specialists or educators.2,13 Most childhood have been associated with
the child to choose the relevant
apps also generally are not designed fewer minutes of sleep per night.24
answers.8 Starting at 15 months of
for a dual audience (ie, both parent
age, toddlers can learn novel words Even infants exposed to screen
and child).2,14 It is important to
from touchscreens in laboratory- media in the evening hours show
emphasize to parents that the higher-
based studies but have trouble significantly shorter night-time sleep
order thinking skills and executive
transferring this knowledge to the duration than those with no evening
functions essential for school
3-dimensional world.9 However, screen exposure.25 Mechanisms
success, such as task persistence,
it should be noted that these underlying this association include
impulse control, emotion regulation,
experiments used specially designed arousing content26 and suppression
and creative, flexible thinking, are
apps that are not commercially of endogenous melatonin by blue
best taught through unstructured
available. light emitted from screens.27
and social (not digital) play,15 as
Many parents now use video-chat (eg, well as responsive parent–child
interactions.16
Child Development
Skype, FaceTime) as an interactive
media form that facilitates social Digital books (also called “eBooks,” Population-based studies continue to
connection with distant relatives. books that can be read on a screen) show associations between excessive
New evidence shows that infants and often come with interactive television viewing in early childhood
toddlers regularly engage in video- enhancements that, research and cognitive,28–30 language,31,32 and
chatting,10 but the same principles suggests, may decrease child social/emotional delays,33–36 likely
regarding need for parental support comprehension of content or parent secondary to decreases in parent–
would apply in order for infants and dialogic reading interactions when child interaction when the television
toddlers to understand what they are visual effects are distracting.17 is on37 and poorer family functioning
seeing. Parents should, therefore, be in households with high media use.37
instructed to interact with children An earlier age of media use onset,
In summary, for children younger
during eBook reading, as they would greater cumulative hours of media
than 2 years, evidence for benefits
a print book. use, and non-PBS content all are
of media is still limited, adult
significant independent predictors
interaction with the child during
of poor executive functioning in
media use is crucial, and there
HEALTH AND DEVELOPMENTAL preschoolers.38 Content is crucial:
continues to be evidence of harm
CONCERNS experimental evidence shows that
from excessive digital media use, as
switching from violent content
described later in this statement. Obesity to educational/prosocial content
Heavy media use during preschool results in significant improvement
years is associated with small but in behavioral symptoms, particularly
PRESCHOOL MEDIA AND LEARNING
significant increases in BMI,18 may for low-income boys.12 Notably,
Well-designed television programs, explain disparities in obesity risk the quality of parenting can modify
such as Sesame Street, can in minority children,19 and sets associations between media use
improve cognitive, literacy, and the stage for weight gain later and child development: one study
social outcomes for children 3 to in childhood.20 Although many found that inappropriate content

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

 89

and inconsistent parenting had will allow children to reap the most • For parents of children 18 to
cumulative negative effects on low- benefit from what they view. 24 months of age who want to
income preschoolers’ executive As digital technologies become more introduce digital media, advise
function, whereas warm parenting ubiquitous, pediatric providers that they choose high-quality
and educational content interacted to must guide parents not only on the programming/apps and use them
produce additive benefits.39 duration and content of media their together with children, because
child uses, but also on (1) creating this is how toddlers learn best.
Child characteristics also may Letting children use media by
influence how much media children unplugged spaces and times in their
homes, because devices can now themselves should be avoided.
consume: excessive television
viewing is more likely in infants be taken anywhere; (2) the ability • Guide parents to resources for
and toddlers with a difficult of new technologies to be used in finding quality products (eg,
temperament40,41 or self-regulation social and creative ways; and (3) Common Sense Media, PBS Kids,
problems,42 and toddlers with social- the importance of not displacing Sesame Workshop).
emotional delays are more likely sleep, exercise, play, reading aloud,
and social interactions. Realistically, • In children older than 2 years,
to be given a mobile device to calm limit media to 1 hour or less per
them down.43 pediatric providers will need to know
how to help parents find resources day of high-quality programming.
finding appropriate content, tools Recommend shared use between
Parental Media Use parent and child to promote
for monitoring or limiting child use,
Parents’ background television ideas for play or activities in which enhanced learning, greater
use distracts from parent–child to engage rather than digital play, interaction, and limit setting.
interactions44 and child play.45 and how parents can limit their own • Recommend no screens during
Heavy parent use of mobile devices media use (see HealthyChildren. meals and for 1 hour before
is associated with fewer verbal and org for examples); each of these can bedtime.
nonverbal interactions between be built into the Family Media Use
parents and children46 and may be Plan (see the American Academy • Problem-solve with parents facing
associated with more parent-child of Pediatrics guide to developing a challenges, such as setting limits,
conflict.47 Because parent media use plan at www.healthychildren.org/ finding alternate activities, and
is a strong predictor of child media MediaUsePlan). calming children.
habits,48 reducing parental media
Families
use and enhancing parent–child
RECOMMENDATIONS
interactions may be an important • Avoid digital media use (except
area of behavior change. Pediatricians video-chatting) in children younger
than 18 to 24 months.
• Start the conversation early. Ask
parents of infants and young • For children ages 18 to 24 months
CONCLUSIONS: CLINICAL
IMPLICATIONS children about family media use, of age, if you want to introduce
their children’s use habits, and digital media, choose high-quality
In summary, multiple developmental media use locations. programming and use media
and health concerns continue to exist • Help families develop a together with your child. Avoid
for young children using all forms Family Media Use Plan solo media use in this age group.
of digital media to excess. Evidence (www.healthychildren.org/ • Do not feel pressured to introduce
is sufficient to recommend time MediaUsePlan) with specific technology early; interfaces are so
limitations on digital media use for guidelines for each child and intuitive that children will figure
children 2 to 5 years to no more than parent. them out quickly once they start
1 hour per day to allow children
ample time to engage in other • Educate parents about brain using them at home or in school.
activities important to their health development in the early years • For children 2 to 5 years of age,
and development and to establish and the importance of hands-on, limit screen use to 1 hour per day
media viewing habits associated unstructured, and social play to of high-quality programming,
with lower risk of obesity later build language, cognitive, and coview with your children, help
in life.49 In addition, encouraging social-emotional skills. children understand what they are
parents to change to educational and • For children younger than 18 seeing, and help them apply what
prosocial content and engage with months, discourage use of screen they learn to the world around
their children around technology media other than video-chatting. them.

PEDIATRICS Volume 138, number 5, November 2016 3

 90

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42. Radesky JS, Silverstein M, Zuckerman parent-child interaction. Child Dev. caregivers and children during meals
B, Christakis DA. Infant self-regulation 2009;80(5):1350–1359 in fast food restaurants. Pediatrics.
and early childhood media exposure. 2014;133(4). Available at: www.
45. Schmidt ME, Pempek TA, Kirkorian HL,
Pediatrics. 2014;133(5). Available at: pediatrics.org/cgi/content/full/133/4/
Lund AF, Anderson DR. The effects of
www.pediatrics.org/cgi/content/full/ e843
background television on the toy play
133/5/e1172
behavior of very young children. Child 48. Jago R, Stamatakis E, Gama A, et al.
43. Radesky JS, Peacock-Chambers E, Dev. 2008;79(4):1137–1151 Parent and child screen-viewing time
Zuckerman B, Silverstein M. Use of
46. Radesky J, Miller AL, Rosenblum KL, and home media environment. Am J
mobile technology to calm upset
Appugliese D, Kaciroti N, Lumeng JC. Prev Med. 2012;43(2):150–158
children: associations with social-
emotional development. JAMA Pediatr. Maternal mobile device use during a
49. American Academy of Pediatrics,
2016;170(4):397–399 structured parent-child interaction
Council on Communications and
task. Acad Pediatr. 2015;15(2):238–244
44. Kirkorian HL, Pempek TA, Murphy Media. Media use in school-aged
LA, Schmidt ME, Anderson DR. The 47. Radesky JS, Kistin CJ, Zuckerman B, children and adolescents. Pediatrics.
impact of background television on et al. Patterns of mobile device use by 2016;138(5):e20162592

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

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Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

American Academy of
Pediatrics:
2016 Technical Report
Children and Adolescents and
Digital Media

49 Click here for Algorithm

Click here for Table of Contents
 94

TECHNICAL REPORT

Children and Adolescents

and Digital Media
Yolanda (Linda) Reid Chassiakos, MD, FAAP, Jenny Radesky, MD, FAAP, Dimitri Christakis, MD, FAAP, Megan A.
Moreno, MD, MSEd, MPH, FAAP, Corinn Cross, MD, FAAP, COUNCIL ON COMMUNICATIONS AND MEDIA

Today’s children and adolescents are immersed in both traditional and new abstract
forms of digital media. Research on traditional media, such as television,
has identified health concerns and negative outcomes that correlate with
the duration and content of viewing. Over the past decade, the use of digital
media, including interactive and social media, has grown, and research
evidence suggests that these newer media offer both benefits and risks This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have
to the health of children and teenagers. Evidence-based benefits identified filed conflict of interest statements with the American Academy
from the use of digital and social media include early learning, exposure of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
to new ideas and knowledge, increased opportunities for social contact Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
and support, and new opportunities to access health promotion messages
and information. Risks of such media include negative health effects on Technical reports from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
sleep, attention, and learning; a higher incidence of obesity and depression; external reviewers. However, technical reports from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
exposure to inaccurate, inappropriate, or unsafe content and contacts; and organizations or government agencies that they represent.
compromised privacy and confidentiality. This technical report reviews the
The guidance in this report does not indicate an exclusive course of
literature regarding these opportunities and risks, framed around clinical treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
questions, for children from birth to adulthood. To promote health and
wellness in children and adolescents, it is important to maintain adequate All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
physical activity, healthy nutrition, good sleep hygiene, and a nurturing revised, or retired at or before that time.
social environment. A healthy Family Media Use Plan (www.healthychildren. DOI: 10.1542/peds.2016-2593
org/MediaUsePlan) that is individualized for a specific child, teenager, or PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
family can identify an appropriate balance between screen time/online time
Copyright © 2016 by the American Academy of Pediatrics
and other activities, set boundaries for accessing content, guide displays
of personal information, encourage age-appropriate critical thinking and FINANCIAL DISCLOSURE: The authors have indicated they do
not have a financial relationship relevant to this article to
digital literacy, and support open family communication and implementation disclose.
of consistent rules about media use.
FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have

INTRODUCTION indicated they have no potential conflicts of interest to
disclose.
What Are the Differences Between Traditional Media and New Digital or
Social Media? To cite: Reid Chassiakos Y, Radesky J, Christakis D, et al.,
AAP COUNCIL ON COMMUNICATIONS AND MEDIA. Children
and Adolescents and Digital Media. Pediatrics. 2016;138(5):
Today’s generation of children and adolescents are surrounded by and
e20162593
immersed in a digital environment. Traditional media, such as television

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 95

(TV), radio, and periodicals, have in changes in the patterns of media access to mobile technology and the
been supplemented by new digital use. For example, in 1970, children Internet in lower-income families,
technologies that promote interactive began to regularly watch TV at 4 a smaller study in 2015 called this
and social engagement and allow years of age, whereas today, children disparity into question by showing
children and teenagers instant access begin interacting with digital media that almost all (96.6%) 0- to 4-year-
to entertainment, information, and at 4 months of age. olds recruited from a low-income
knowledge; social contact; and pediatric clinic had used mobile
As new media platforms and social
marketing. Traditional media, also devices, and 75% owned their own
media have been incorporated into
referred to as broadcast media, device.5 This study also showed
children’s media diets, hours spent
typically were created externally by an that most 2-year-olds used mobile
in TV viewing have slowly decreased
established production source, such as devices on a daily basis and that most
over the past 2 decades. Loprinzi
a film studio, TV network, or editorial of the 1-year-olds assessed (92.2%)
and Davis1 examined trends in
staff and were provided either to had already used a mobile device.
parent-reported TV viewing among
individuals or to a broader audience Although a digital divide likely still
preschoolers 2 to 5 years of age
for passive viewing or reading. In exists in terms of access to quality
(n = 5724) and children 6 to 11 years
contrast, newer digital media, which content and reliable Wi-Fi, it is now
of age (n = 7104) between 2001 and
include social and interactive media, clear that most young children seen
2012 using data from the National
are a form of media in which users by a pediatric health care provider
Health and Nutrition Examination
can both consume and actively will have used or have been exposed
Survey (NHANES), showing
create content. Examples include to mobile technology.
significant decreases in mean TV
applications (apps), multiplayer video
viewing over time, primarily for
games, YouTube videos, or video
preschoolers and, to a lesser extent, Exactly what young children are
blogs (vlogs). For children and young
for school-aged children. Non- doing on mobile technology has not
adults today, this evolving integration
Hispanic white boys demonstrated been studied in great detail, because
of passively viewed and interactive
the largest decrease in mean viewing mobile device usage is relatively
media is seamless and natural; the
of 29%, from 2.24 hours of TV per recent and methodologically
distinctions and boundaries between
day down to 1.59 hours of TV per difficult to assess. By parent report,
traditional/broadcast and interactive/
day. Despite these decreases, the most children in the Kabali et al
social media have become blurred or
majority of parents still reported that study5 watched YouTube or Netflix
imperceptible.
their children watched TV for 2 or primarily, and smaller proportions
Digital media allow information more hours per day. watched educational programs
sharing across a variety of media and played early-learning apps
It is unclear whether these decreases
formats, including text, photographs, (eg, alphabet and counting apps).
are in part the result of parents
video, and audio. Today’s video A large minority also played games
heeding expert recommendations
games, for example, often represent a
to limit screen time (evidence or watched cartoons. Common
merging of both traditional and social
would suggest not)2 or whether Sense Media’s Zero to Eight survey
media, as users can virtually “inhabit”
they represent a displacement of has found disparities in the use of
impressively produced worlds and
TV viewing by the use of novel educational media on mobile devices,
interact with other users in remote
platforms. In young children, with 54% of children from higher-
locations. Video game participants
use of mobile devices, such as income families often or sometimes
can even work collaboratively to
smartphones and tablet computers, using educational content on mobile
cocreate virtual worlds. Thus, digital
has risen dramatically since the devices but only 28% of children
media can provide an engaging
Kaiser Family Foundation first from lower-income families doing
experience in which the media
began surveying parents of 0- to so.4 Thus, younger children and
experiences of children and teenagers
8-year-olds about their technology those from lower-income families are
become highly personalized.
use.3 For example, in 2011, 52% more likely to use mobile devices for
of children 0 to 8 years of age had entertainment purposes.
MEDIA USE ESTIMATES access to a mobile device (although
only 38% had ever used one). By How Are Media Being Used in Older
How Are Media Usage Patterns 2013, this access had increased to Children and Teens Today? Which
Changing in Young Children? 75% of 0- to 8-year-olds.4 Although Modes of Use Are Most Popular?
The evolution of media from these national surveys continued to
traditional to newer forms of digital demonstrate a digital divide on the Studies show that social media use
media in the past decade has resulted basis of economic status, with less patterns and rates among older

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children and adolescents have to message your opponent while GAMIFICATION AND ADVERTISING
continued to grow over the past engaging in a remote video game
decade, aided in part by the recent or tweet while watching a TV What Is Gamification? What Is the
rise in mobile phone use among show, viewers and gamers often Impact of Gamification on Media Use
children and teenagers. At present, link their entertainment to social by Children?
approximately three-quarters of media. Modes of communication Gamification applies gaming
teenagers own a smartphone, 24% have become more fluid, with elements to a real-world activity
of adolescents describe themselves conversations jumping back and in a seamless, user-friendly, and
as “constantly connected” to the forth between text messages to attractive way. Commercial video
Internet6 and 50% report feeling social media sites. Text messages games have incorporated cutting-
“addicted” to their phones.7 Mobile also may include links to media, such edge graphics, behavioral reinforcers
apps provide a breadth of specific as personal videos, YouTube videos, (ie, for reaching certain levels of
functions, such as gaming, photo and links to Web sites and social play), and exciting stories, which
and video sharing, and global networking sites. have been delivered through
positioning system monitoring. Pew data from 2012 suggest that stationary personal computers,
Social media sites and their teenagers between 14 and 17 dedicated gaming consoles, or
associated mobile apps provide years of age sent a median of 100 multiplayer networks. One key
a platform for users to create an texts a day. With all likelihood, this difference today is the portability
online identity, communicate with number will continue to increase achieved via smartphones, mobile
others, and build a social network. as new data become available. Wi-Fi, and broad social networks,
Among the myriad accessible social Texting no longer is limited to which has changed how and
networking sites, Facebook remains cellular phone systems but can be where games can be played and
the most popular, with 71% of 13- facilitated by messaging apps, such how gaming functions can be
to 17-year-olds surveyed by the as Kik or WhatsApp. Pew data from applied. These portable “games”
Pew Research Center in 2014 and 2015 show that these apps are most can now be integrated into daily
2015 reporting using this site/app.6 popular with Latino (46%) and life by functioning as sources for
However, adolescents today do not African-American (47%) teenagers, information and guidance and by
typically dedicate themselves to compared with white teenagers providing motivation to achieve
just 1 site; most teenagers maintain (24%).6 academic and wellness goals. For
a “social media portfolio” of example, the Nike+ app tracks
several selected sites including, as Video games also remain very
exercisers’ routes, pace, steps,
indicated by rates of use in the Pew popular among families; it is
distance, and time and challenges
survey, Instagram (52%), Snapchat estimated that 4 out of 5 households
runners to compete with friends
(41%), Twitter (33%), Google+ own a device used to play video
and improve their performance.
(33%), Vine (24%), Tumblr (14%), games, and approximately half
Such design also serves to reinforce
and other social media (11%).6 of US homes own a dedicated
behavior (both health behaviors and
game console.8 Video games also
for using the app), resulting in more
are available via apps on mobile
As communication moves from engagement with both.11
devices. Additionally, apps that
face-to-face and voice-only phone
have a practical function are also
conversations to more screen-
being marketed with a gaming How Have Mobile and Social Media
to-screen interactions via apps,
such as FaceTime or Skype, daily
perspective; this approach is known Changed the Ability of Advertisers to
as “gamification.” Reach Children and Teenagers?
communication is becoming
intertwined with screen time. It is common for adolescents today Newer media have provided
Texting, using a smartphone to engage in more than 1 form of expanding opportunities for
keyboard to send a written message media at the same time, a practice marketers and advertisers to adapt
or a visual symbol (emoji) to another referred to as media multitasking. their messages to reach millions
smartphone, also has become a This multitasking may include of children and teenagers.12 These
prominent means of communication watching TV and using a computer9 newer forms of media may broaden
for teenagers. or being online and engaging in more the types of products and behaviors
than 1 activity. In one study of older to which children and adolescents
Lines are also becoming adolescents, approximately 50% are exposed. For example, although
blurred between media use of the time students were online, restrictions may exist to limit
for communication versus for they were engaged in more than 1 exposure to advertisements for
entertainment. With the ability activity.10 alcohol in traditional media, research

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suggests that the major alcohol Pediatrics (AAP) recommendations toddlers lose the knowledge learned
brands maintain a strong presence on to discourage media exposure over time without repetition.23
Facebook, Twitter, and YouTube.13,14 for children younger than 2 years
From a marketing perspective, were based on research on TV and More recent research has shown that,
social media are consumer focused, videos, which showed that in-person under particular conditions, children
allowing interaction and input interactions with parents are much between 15 and 24 months of age
that can build relationships.15 more effective than video for learning can learn from repeated viewing
Social media also allow targeted of new verbal or nonverbal problem- of video demonstrations without
ads that reflect content that users solving skills.17 This research showed adult help. Dayanim and Namy
have posted on their own pages. In that infants and toddlers experience showed that 15-month-olds could
one study, researchers found that what was referred to as the “video learn the meaning of sign language
placing content related to exercise deficit:” difficulty learning from symbols after 3 weeks of watching
or nutrition as a status update on 2-dimensional video representations a commercially available video 4
Facebook led to advertisements at younger than 30 months of age. times per week.24 However, children
for sports gear and diets as well as The video deficit is thought to be in a comparison study group whose
junk food.15 Thus, social media ads attributable to infants’ and young parents used a book of sign language
can directly address individuals or toddlers’ lack of symbolic thinking, symbols to teach the content retained
groups who would be interested and immature attentional controls, and more knowledge about the symbols’
responsive. Social media ads may the memory flexibility required meanings for a longer period of time.
also be interactive and are more to effectively transfer knowledge
affordable to create and disseminate. from a 2-dimensional platform to a Building parasocial relationships
However, this ability for marketers to 3-dimensional world.18 Before 2 years with TV or video characters (ie, the
reach children through social media of age, children are still developing perceived relationship that audience
is understudied. cognitive, language, sensorimotor, and members develop with characters
Marketing to parents of young social-emotional skills, which require who speak to them, such as Elmo or
children also is common, because hands-on exploration and social Dora) also has been shown to improve
advertisers know that many interaction with trusted caregivers for toddlers’ learning. Calvert et al25
parents fear that their children successful maturation. showed that, after 3 months of playing
may fall behind in the skilled use of with a personalized interactive toy,
technology without early exposure Therefore, adult interaction 21-month-olds could learn how to
to it.16 In reality, parents can be remains crucial for toddlers to learn stack cups from a video demonstration
reassured that their children will effectively from digital media. For by the same character, suggesting
learn to use digital media quickly example, from 12 to 24 months of that building an emotional bond with
when they are introduced at home or age, toddlers can begin to learn novel an on-screen character improves
in school. words from commercially available learning potential. However, a primary
“word learning” videos, but only if limitation of such experimental studies
their parents watch with them and is that they do not examine how
BENEFITS AND OPPORTUNITIES OF reteach the words, essentially using repeated media use displaces other
MEDIA USE the videos as a learning scaffold to activities, and they do not examine
build the language skills.19,20 In one longer-term outcomes. For example, in
Fortunately, new media use is longitudinal study of low-income the study by Calvert and colleagues,25
not without its benefits, but these families, 14-month-olds whose children randomly assigned to
benefits largely depend on a child’s mothers had talked with them during the group that did not receive the
age and developmental stage, a child’s educational TV programming since interactive toy for 3 months actually
characteristics, how the media are infancy showed more advanced scored better in terms of language
used (eg, with a parent or without), language development than infants development at 21 months of age.
and the media content and design. whose mothers did not talk with
Early Childhood them during media use (although Are Touchscreens More Educational?
this finding also may have reflected
At What Age Can Infants and Toddlers how much mothers spoke to children Pedagogic theory has long
Learn From Screens? in general).21 The few experimental emphasized that interaction improves
Evidence continues to show limited studies showing independent learning. This understanding
educational benefits of media for learning of words from videos at this has been the motivation for
children younger than 2 years. age have been limited by their low recommending coviewing of
Earlier American Academy of ecologic validity22 or have shown that media, along with evidence that

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parent interaction increases young programs, such as Sesame Street and in the educational section of app
children’s engagement with media Mister Rogers’ Neighborhood) can stores have evidence-based design
and understanding of content.26 demonstrably improve cognitive, input with demonstrated learning
The interactivity of new media via linguistic, and social outcomes effectiveness. In fact, recent reviews
touchscreens allows apps to “know” for children 3 to 5 years of age. of hundreds of toddler/preschooler
whether a child is responding Although there have been few large apps labeled as educational have
accurately and tailor responses, community-based, randomized demonstrated that most apps show
reinforcement, and next steps to the trials, many observational studies low educational potential, target
child’s input. Theoretically, this may and some small experimental ones only rote academic skills (eg, ABCs,
increase educational potential by have demonstrated that preschoolers colors), are not based on established
providing scaffolding to build skills at can learn literacy, numeracy, and curricula, and include almost no
the child’s edge of competence. prosocial skills from high-quality TV input from developmental specialists
programs.31,32 In addition, Sesame or educators.35,36 An additional
Empirical evidence regarding Workshop and other child content concern is that the formal features
interactive media use in infants and creators have been responding (ie, bells and whistles) that are
toddlers is sparse. At 24 months of to current child health and designed to engage the child in an
age, a child can learn words from developmental needs (eg, obesity, interactive experience may actually
live video-chatting with a responsive resilience) by crafting programming decrease the child’s comprehension
adult27 or from carefully designed, aimed at teaching parents and or distract from social interaction
interactive screen interfaces that children relevant knowledge and between caregivers and children
prompt the child to tap on relevant skills. during use, as has been shown
learning items.28 Starting at 15 for e-books,37 which is important,
months of age, toddlers can learn Choosing PBS content has been found because active parent involvement
novel words from touchscreens to be protective of poor executive in both digital play and book reading
in laboratory-based studies (with function outcomes observed in improves children’s learning from
specially designed, not commercial, children who start consuming media the experience.38,39
apps) but have trouble transferring in early infancy.33 Preschoolers
this knowledge to the 3-dimensional randomly assigned to change from One reason that children may be
world,29 particularly if they regularly inappropriate or violent content to less socially engaged during digital
use touchscreen platforms to view high-quality prosocial programming play is that gaming design involves
entertainment media. were found to have significant behavioral reinforcement meant
improvements in their externalizing to achieve a maximum duration of
and internalizing behavior,32 which engagement, which may explain
Is Skyping Appropriate for Infants and
also speaks to the importance of why interrupting children’s digital
Toddlers?
content. For families who find it play leads to tantrums, particularly
Many parents now use video-chat (eg, difficult to modify the overall amount when games or videos are set on
Skype, Facetime) as an interactive of media use in their homes, changing autoadvance.40 To address these
media form that facilitates social to high-quality content may be a concerns, academic and industry
connection with distant relatives. more actionable alternative; to make leaders have recently recommended
New evidence shows that infants and these changes, pediatric providers creating digital products for children
toddlers regularly engage in video- can direct them toward curation that are appropriately engaging, but
chatting,30 but the same principles services, such as Common Sense not distracting; that are designed
regarding need for parental support Media, for reviews of videos, apps, TV to be used by a dual audience (ie,
would apply in order for infants and shows, and movies. both parent and child) to facilitate
toddlers to understand what they are family participation in media use and
seeing. Because video-chat episodes Are “Educational” Apps and e-Books modeling of more effective social and
usually are brief,30 promote social Really Educational? learning interactions35,41; and that
connection, and involve support from have automatic “stops” as the default
As content from PBS high-quality
adults, this practice should not be design to encourage children and
programs is translated into apps and
discouraged in infants and toddlers. caregivers to pause the game use and
game formats (eg, Martha Speaks, Big
turn to the 3-dimensional world.40
Bird’s Words, and Cookie Monster’s
What Is the Best Approach to Selecting Challenge apps), educational benefits One recent app, for example,
Quality Content for Young Children? have been shown in preschoolers.34 demonstrates such an adult–child
High-quality TV programs (eg, Unfortunately, very few of the dyad-centered design. Bedtime Math
Public Broadcasting Service [PBS] commercially available apps found creates a platform and a structure for

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parents and children to read stories How Can Social Media Be Used To Social media may be used to enhance
and answer math problems together Promote Improved Health? health and wellness and promote
on a nightly basis. It is one of the healthier behaviors, such as smoking
few apps that has been tested in a Health benefits of social media may cessation and balanced nutrition.44
randomized controlled community- include enhanced access to valuable However, there are a myriad of
based trial and shown benefits.42 support networks. These networks easily accessible Web sites and
Embedding, indeed requiring, social may be particularly helpful for social networks that facilitate and
interactivity for functionality may patients with ongoing illnesses, even promote unhealthy behaviors,
hold great promise for even younger conditions, or disabilities46 as well as such as disordered eating. “Pro-ana”
children as well. However, recent for those identifying as lesbian, gay, (anorexia nervosa) and “pro-mia
population-based surveys suggest bisexual, transgender, questioning, (bulimia)” sites, for example, are
that joint media engagement43 (and or intersex (LGBTQI) seeking forums in which peers actively
designs to facilitate it)35 is not as helpful information or a welcoming support restricted eating or purging
common as individual use. community. Recent literature and frequently offer life-threatening
indicates that transgender teenagers suggestions and advice.49
School-Aged Children and Teenagers who feel supported by their families
Do Screen Time Limits Apply for
How Can Media Use in Older Children have lower rates of depression Children With Disabilities Who Use
and Teenagers Increase Collaboration and anxiety.47 Connections with a Mobile Devices To Communicate?
and Tolerance? supportive online community (eg,
An important benefit from new
the “It Gets Better” project) may be
Research studies as well as anecdotal media has been the development and
beneficial to teenagers who identify
reports have suggested benefits of use of technology-aided interventions
as LGBTQI, but most such programs
media use for today’s children and in children and adolescents with
have not been studied to determine
adolescents, such as communication disabilities, particularly through
effects and outcomes.
and engagement.44 Additional benefits the expanding use of assistive and
include exposure to new ideas and Research also supports the use of interactive digital media to learn and
immersive learning experiences. social media to foster social inclusion to communicate in youth with autism
Many social media platforms provide or peer-to-peer connection among spectrum disorder (ASD),50 physical
tools that students can use to touch patients who might otherwise feel disabilities, speech impairment, and
base with and collaborate with excluded, for example, patients intellectual disability to learn and
others on projects. Communicating with obesity48 or mental illness.13 communicate.51 However, because
across distance is made easier by Individuals with mental illness report teenagers with ASD have higher
social media; these communications greater social connectedness and rates of problematic media use,52,53
may include connecting via video- feelings of group belonging when limits still should be placed on
chatting with family or friends using social media in this manner, entertainment media use, such
who are separated geographically. because they foster the ability to as watching videos or playing
Traditional and social media can also share personal stories and strategies gaming apps, which can represent a
raise awareness of current events for coping with challenges.14 The restricted interest in children with
and issues, and social media can advantages of these connections ASD.
provide tools to promote community include avoiding feared stigma,
participation and civic engagement. enhancing social networks, learning
A study by Kidd and Castano45 about resources from peers online, HEALTH AND DEVELOPMENTAL RISKS
indicated that reading literary fiction and gaining information and OF MEDIA USE
improves empathy in children. insight. However, risks of such
interactions can include exposure What Are the Developmental and
Although books are a traditional
to misinformation, negativity or Behavioral Risks in Early Childhood?
form of media, the study indicates
that exposure to character-focused hostility in communications, delays in Population-based studies continue
media can break stereotypes and seeking out traditional resources, and to show associations between
help children understand people unhealthy influences. excessive TV viewing in early
from whom they differ. Internet Young adults describe the benefits childhood and cognitive,54–56
usage/digital media consumption of seeking health information language,57,58 and social/emotional
is positioned to have a similar online and through social media delays.59–62 Possible mechanisms
impact, which is important to help and recognize these channels as for these outcomes include the
children learn about, understand, and useful supplementary sources of effects of viewing inappropriate,
empathize with marginalized groups. information to health care visits.15 adult-oriented content54 (as well as

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some inappropriate child-directed temperament69,70 or self-regulation Studies of older children and

content),58 a decrease in parent–child problems.71 Toddlers with social- teenagers show clear correlations
interaction when the TV is on,63 emotional delays are more likely between increases in hours of TV
and poorer family functioning in to be given a mobile device to calm viewing and higher risk of obesity.80
households with high media use.60 them down,72 especially if their In a 1996 study of 5- to 10-year-olds,
parents are facing parenting control the odds of being overweight were
An earlier age of media use onset,
challenges. However, it is not clear 4.6 times greater for youth watching
greater cumulative hours of media
whether more “difficult” infants more than 5 hours of TV per day
use, and content that is not of
and toddlers have more positive compared with those watching 0 to 2
high quality all are significant
or negative outcomes over time hours.81 This study greatly influenced
independent predictors of poor
when exposed to longer media the AAP recommendations for 2
executive functioning (impulse
duration, which likely depends hours or less of sedentary screen
control, self-regulation, mental
on content quality and other time daily for children 2 through
flexibility)33 as well as “theory of
contextual factors. For example, 18 years of age. However, a more
mind” deficits (ie, the ability to
Linebarger et al73 found that the recent study in the Netherlands of
understand others’ thoughts and
quality of parenting can modify children 4 through 13 years of age
feelings) in preschoolers.64 Media
associations between media use and found that watching TV over 1.5
multitasking, once thought to be a
child development: inappropriate hours per day was a significant
pastime only of only adolescents,
content and inconsistent parenting risk factor for obesity. In this study,
now is observed even in children
had cumulative negative effects on however, an association between
younger than 4 years.13 The orienting
low-income preschoolers’ executive TV and obesity was only found for
response to novel stimuli is very
function, and warm parenting and children 4 through 9 years of age.82
strong in young children, so their
educational content interacted to A large international study with almost
attention is drawn to the engaging
produce additive benefits. 300 000 children and adolescents
and quickly changing features of
found that watching between 1 and
digital media, such as animation,
3 hours of TV a day led to a 10%
sounds, and highlighted features Is Media Use Linked to Obesity? to 27% increase in risk of obesity.83
they can tap and swipe.65 These
High levels of media use are linked These more recent studies suggest
features, however, may decrease
to obesity and cardiovascular risk74 that setting limits of TV viewing to
young children’s comprehension.66
throughout the life course, but these between 1 and 1.5 hours a day
It is unknown whether rapid shifts
associations are observed starting may be more effective to prevent
in attention to and from digital
in early childhood. For example, obesity than the 2 hours per day
stimuli may have long-term effects
heavy media use during preschool standard presented in earlier AAP
on children’s attention span or
years is associated with small but recommendations.
information processing.
significant increases in BMI,75 which
Because strong associations between sets the stage for greater weight gain Additional studies have identified
violent media content and child later in childhood. The association relevant factors around TV viewing
aggressive behavior have been between using ≥2 hours of media per beyond solely the number of hours
clearly documented,67 parents should day and obesity persists even after for families to use in developing
continue to monitor the content of adjusting for children’s psychosocial household rules. Another recent
their children’s media. Today, more risk factors or behavioral problems.76 study found that the association
children own and use mobile devices Research in preschoolers often uses between TV viewing and obesity risk
independently,13 making monitoring a 2-hour cutoff to define excessive was only significant for children who
and regulation much more difficult.16,68 media use, but a recent study of were already at the higher end of
More research is needed on how 2-year-olds found that BMI increased the BMI distribution.84 A large study
parents can best supervise and guide for every hour per week of media using a national dataset of children
their children’s media use. consumed.77 Moreover, media use reported that it was not just the
behaviors may explain some of the hours of TV viewing that predicted
Are Certain Children or Families obesity risk disparities among young obesity, but the combination of
More Susceptible to These Risks? black and Hispanic children.78 None low physical activity and high
TV has been used as an “electronic of these studies examined mobile sedentary TV viewing that was most
babysitter” for decades, but recent media specifically, which may be contributory to obesity risk.85 A
evidence suggests that excessive more easily used during meals and, 2008 study directly examined the
media use is more likely in infants therefore, distract children from AAP recommendations for 2 hours
and toddlers with a “difficult” satiety cues.79 a day or less of sedentary media

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consumption and found that boys mobile device in the bedroom in associations between electronic
who exceeded 2 hours a day of early childhood have been associated media use in bed before sleep,
sedentary media use were 1.7 with fewer minutes of sleep per sleep difficulties, and symptoms of
times more likely to be overweight night, especially among children depression in teenagers.
compared with those who had 2 of racial/ethnic minority groups.91
hours a day or less of sedentary Later bedtimes after evening media Daytime screen use may also affect
media use. The results for girls were use and violent content in the media sleep. According to a Norwegian
much less impressive, in that girls also may be contributing factors,92 study, daytime and bedtime use
with over 2 hours a day of sedentary and suppression of endogenous of electronic devices both affected
media use were only 1.2 times more melatonin by blue light emitted from sleep measures, with an increased
likely to be overweight compared screens is another possible cause.93 risk of short sleep duration, long
with girls who had 2 hours or less of Associations between media and sleep onset latency, and increased
media use time.86 sleep are seen in infants as well; 6- to sleep deficiency. A dose–response
12-month-olds who were exposed to relationship emerged between
The association between TV viewing sleep duration and use of electronic
and obesity previously attributed screen media in the evening hours
showed significantly shorter night- devices.100 Ensuring that children
to food advertising87 may now be and teenagers obtain the necessary
decreased, because children watch time sleep duration than those who
had no evening screen exposure.94 hours of healthy sleep is an
more videos from streaming services important goal of a Family Media
(eg, Netflix, Hulu), which do not Studies of older children and Use Plan (www.healthychildren.org/
contain advertisements, but this has teenagers have found that MediaUsePlan).
yet to be studied. participants with higher social media
Another area of obesity risk is the use95 or who sleep with mobile What Are the Risks of Social Media
presence of a TV in the bedroom. A devices in their room96,97 were at Use In School-Aged Children and
2007 study found that having a TV greater risk for sleep disturbances. Teenagers?
in the bedroom was an independent One study of adults found that taking
a phone into the bedroom led to The links between media and health
risk factor for obesity. A more recent behaviors among adolescents
study found that the combination longer sleep latency, worse sleep
quality, more sleep disturbance, have been backed by decades of
of a TV in the bedroom and greater evidence in traditional media.101–104
use of screen time had the strongest and more daytime dysfunction.98
This study illustrates the multiple Studies have shown that exposure
association with obesity.88 to alcohol or tobacco use or risky
mechanisms by which media use
Fortunately, studies also suggest around bedtime, or during bedtime, sexual behaviors in TV or movies is
that making efforts to reduce can disrupt sleep and affect daytime associated with initiation of these
children’s sedentary media use function. behaviors,101,102,105,106 leading some
can have positive health effects. An to describe TV as a “superpeer.”107
intervention study focused on third Bruni et al90 studied the use of A growing body of evidence suggests
and fourth graders worked with the technology on sleep quality in that these influences also are
participants to reduce time spent adolescents and preadolescents. strong in digital and social media.
watching TV and playing video Adolescents’ bad sleep quality was Several studies have illustrated
games. The study demonstrated associated consistently with greater that adolescents’ displays on social
that children in the intervention mobile phone use and the number media frequently include portrayal
group reported reduced TV viewing of devices in the bedroom, and in of risky health behaviors, such as
and meals in front of the TV and preadolescents, bad sleep quality illegal alcohol use or overuse, illicit
had reduced BMIs, illustrating that was associated with greater Internet substance use, high-risk sexual
interventions to reduce sedentary use and later media turn-off time. behaviors, and harmful behaviors,
media use can positively impact The authors concluded that evening such as self-injury and disordered
health behaviors as well as BMI.89 circadian preference, mobile phone eating.108–112 A growing body of
and Internet use, the number of other evidence suggests that peer viewers
activities engaged in after 9:00 PM, of this content are influenced to
How Does Media Use Affect Sleep? see these behaviors as normative
later media turning-off time, and the
There is a growing body of evidence number of devices in the bedroom and desirable.113–115 Social media
that suggests that media use have different, but significant, combine the power of interpersonal
negatively affects sleep.90 Increased negative influences on sleep quality persuasion with the reach of
duration of media exposure and in preadolescents and adolescents.90 mass media. Fogg described this
the presence of a TV, computer, or Similarly, Lemola et al99 reported mass interpersonal persuasion as

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“the most significant advance in when more TV viewing displaces Despite efforts by some social media
persuasion since radio was invented real-life experiences that might build sites to protect privacy or even to
in the 1890s.”116 self-esteem. delete content after it is viewed,
The interactive and selective privacy violations and content
Although restrictions exist to protect sharing are always possible.126,127
youth and children from exposure components of social media may
offset some of these traditional media This risk illustrates the need for
to alcohol, tobacco, and marijuana continued discussion about media
advertisements on traditional media drawbacks, because social media
use in moderation can enhance and privacy with children and
platforms, such as TV, there is teenagers with parents, caregivers,
concern about the extent to which social support and connection.
However, use in moderation and the teachers, and other responsible
youth are exposed to promotion of adults. These discussions should be
these substances on social media specific way in which social media
are used may be the key. Previous included in schools through their
Web sites from marketers or peers. digital citizenship programs and in
For example, research from both research has suggested a U-shaped
relationship between Internet use pediatric well-child examinations
the United States and the United with parents and teenagers.
Kingdom indicate that the major and depression, with increased
risks for depression at both the high Pediatricians can introduce and
alcohol brands maintain a strong work with families to develop a
advertising presence on Facebook, and low ends of Internet use.118,119
A recent study examined social Family Media Use Plan (see the AAP
Twitter, and YouTube.13,14 Targeted guide to making a plan at www.
advertising via social media may media use and depression and found
a positive association.120 Older healthychildren.org/MediaUsePlan)
have a significant effect on adolescent that can mitigate or avoid such risks.
behavior. adolescents who used social media
passively by solely viewing content
reported declines in well-being Is Cyberbullying Different From
How Does Media Use in School-Aged Traditional Bullying?
Children and Teenagers Relate to and life satisfaction, whereas those
Mental Health? who used social media actively by Cyberbullying is commonly defined
interacting with others and posting as “an aggressive, intentional
Research studies have identified content did not experience these act or behavior that is carried
both benefits and concerns regarding declines.121 Another study found that out by a group or an individual,
mental health and media use. In one teenagers who used Instagram to using electronic forms of contact,
longitudinal panel survey, 396 white follow strangers and engage in social repeatedly and over time against a
and black preadolescent boys and comparisons had higher depression victim who cannot easily defend him
girls were assessed to determine the symptoms, but others who followed or herself.”128 Unfortunately, there
long-term effects of TV consumption friends and engaged in less social are many online platforms in which
on global self-esteem. TV exposure comparison had fewer depression bullying may take place, including
was found to be significantly related symptoms.122 These studies illustrate E-mail, blogs, social networking
to self-esteem, but whether it that, beyond the number of hours Web sites/apps, online games,
increased or decreased self-esteem spent on social media, a key factor is and text messaging. There is clear
was influenced by demographic how an individual uses social media. overlap between cyberbullying and
factors. Greater exposure resulted in a
traditional bullying,129 but several
decrease in self-esteem for both white
Do Children and Adolescents features of online bullying present
and black girls and for black boys but
Understand the Privacy Risks new challenges. These challenges
resulted in an increase in self-esteem Associated With Social Media Use? include that perpetrators can
for white boys.117 Analyzing these
bully at any time of day and can be
results, the authors postulate that An important issue across all social
anonymous, the rapidity with which
the majority of the TV content served media and interactive apps is privacy,
information can spread online,130
to reinforce both gender-role and because content that a child or
and the fluidity with which bully and
racial stereotypes, which tended to adolescent chooses to post on any
target roles can switch in the online
be positive for white boys but not the site or app becomes public in some
world. Estimates of the number of
other groups. The authors suggested way. Removal of such content may
youth who experience cyberbullying
that the black children and white be difficult or impossible. Previous
vary, ranging from 10% to 40%,
girls could be internalizing the “social work suggests that adolescents vary
depending on the age group and how
norms” portrayed and using these in their understanding of privacy
cyberbullying is defined.
messages as a basis for self-evaluation, practices, and even among those who
negatively affecting their self-esteem. do know how to set privacy settings, Cyberbullying shares many
There is also an opportunity cost many choose not to do so.123–125 similarities and a few key differences

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with traditional bullying. For levels of depression and lower self- surveyed, 48.5% of girls and 63.6%
example, victims of cyberbullying esteem. Victims were at higher risk of boys had sent a sext, and 70% of
often do not know who the bully is of both suicidal ideation and suicide girls and 82% of boys had received
or why they are being targeted, the attempts. a sext. The authors report that girls
hurtful actions of a cyberbully can expressed significantly more concern
Fortunately, newer studies suggest
reach a child or teenager anytime than boys about how sexting could
that interventions targeting bullying
he or she uses a smartphone or affect their reputation, including
also may reduce cyberbullying.138
computer (so there is no safe haven getting caught by an adult with a sext
Moreno states: “Parents can play
of home), and the bullying messages and how others would think of them.
a role in preventing cyberbullying
can also spread virally through the Fortunately, 52% of respondents said
by educating their children about
Internet to many other people at they would be comfortable talking
appropriate online behaviors. Parents
school or in the community, making with their doctor about sexting.
should have discussions early and
this type of bullying potentially very Pediatricians may, therefore, find
often about their child’s friendships
embarrassing and lasting. their teen patients receptive to a
and relationships to develop and
conversation about sexting and its
Descriptive research has shown maintain open communication
implications and risks.
that vulnerable populations exist about these topics.”139 The Centers
and are more likely to be targeted for Disease Control and Prevention Ybarra and Mitchell, in their article,
for bullying. Youths identifying panel reviewing effective prevention “‘Sexting’ and its relation to sexual
as LGBTQI are more likely to be strategies recommends media activity and sexual risk behavior in a
victimized in bullying dynamics literacy education as a “promising national survey of adolescents,”142
and are at risk online as well.131 approach,” along with collaborative suggest that sexting is related to
Children and adolescents with strategies among teenagers, parents, behaviors indicative of psychosocial
ASD are a population particularly and schools that encourage victims to challenge and risky sexual behavior
vulnerable to bullying (https://www. report cyberbullying and seek adult for some youth. Significant findings
autismspeaks.org/family-services/ support.140 include a higher frequency of sexting
bullying) and could easily be a target among females and lesbian, gay,
for cyberbullying. The 2016 National What Is Sexting and How Can the and bisexual youth. Additionally,
Academies of Sciences, Engineering, Risks of Sexting Be Avoided or a greater number of past-year sex
and Medicine report, “Preventing Addressed? partners and a greater odds of
Bullying Through Science, Policy, depression and substance abuse
Sexting is a serious issue in
and Practice,”132 addressed the were found among teenagers who
adolescence. Sexting is commonly
concept of populations vulnerable sext.
defined as the electronic
to bullying to propose that there is a transmission of nude or seminude Findings related to lesbian, gay, and
need for research that moves beyond images as well as sexually explicit bisexual populations are consistent
descriptive studies and labeling of text messages.111 It is estimated that with previous studies on sexting;
youth as vulnerable and considers approximately 12% of youth 10 to 19 of note, transgender youth were
processes that can explain why years of age have ever sent a sexual not included. Earlier research
individuals may have differences photo to someone else112; sadly, had demonstrated a significant
in their bullying experiences and many youth who have participated in association between sexting and
consequences depending on their sexting report having felt pressured risky sexual behaviors in lesbian, gay,
context. into sending a sext. When dealing bisexual, and transgender youth.142
Previous studies have examined the with youth and sexting, adults,
negative effects that cyberbullying authorities, and schools need to be Ybarra and Mitchell’s study142 found
can have on both bullies and aware that the situation may be more that sexting was indicative of sexual
victims. Victims are more likely complicated. activity and risky sexual behaviors,
to report lower grades and other Spencer et al141 examined sexting and further research may identify
academic problems as a result of the and youth in an urban population; predictive outcomes of sexting.
experience. Similar to traditional 55 youth presenting for care at the One study suggests that sexting
bullying, cyberbullying can lead to Teen Health Center at Children’s may precede sexual intercourse.142
short- and long-term133,134 negative Hospital Los Angeles were surveyed The predictive value of a sexting
social, academic, and health134–137 to evaluate prevalence and sexting history may inform sex education
consequences for both the behaviors, such as forwarding sexts, and HEEADSSS (home, education
perpetrator and target. Both bullies reasons for sending sexts, and youths’ & employment, eating, activities,
and victims often report higher concerns regarding sexting. Of those drugs, sexuality, suicide/depression,

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and safety) assessments. Moreover, and providing safer and less risky Online child sexual exploitation
discussions between pediatricians alternatives for social connections. also may involve recruitment and
and teenagers about sexting may advertisement of children for
indicate risky sexual behaviors and prostitution and other forms of
a number of psychosocial issues, CHILD PORNOGRAPHY AND CHILD exploitation.147 The Internet may
such as depression, anxiety, and ABUSE be used by human traffickers to
low self-esteem, that may be further facilitate movement of victims and to
addressed. How Has Social Media Changed the manage a criminal network.148
Landscape of Child Pornography and
Temple et al143 examined whether Child Abuse? Internet-initiated sex crimes
adolescents who report sexting involving offenders who meet and
Unfortunately, the Internet has groom children online tend to involve
exhibited more psychosocial health also created opportunities for
problems than their nonsexting adolescents rather than very young
the exploitation of children by children: 99% of victims in one
counterparts. The authors reported sex offenders. Online predators
that teen sexting was significantly study were 13 to 17 years old, and
can gain access to children and 48% were 13 to 14 years old. Many
associated with symptoms of teenagers through social networking,
depression, impulsivity, and of these crimes involve face-to-face
chat rooms, E-mail, and online sexual contact, which the victim
substance use. When adjusted for games. Cases of child trafficking,
previous sexual behavior, age, perceives as “consensual.” Sexual
cybergrooming, and sexual abuse relationships in early adolescence
gender, race/ethnicity, and parent for private and commercial
education, however, sexting was only are associated with an increased risk
purposes have increased with the of social, academic, and behavioral
related to impulsivity and substance help of the anonymous cyberspace
use. The authors concluded that adverse outcomes.149,150
environment. For example, online
“while teen sexting appears to grooming leads to establishment of Research has shown that parents
correlate with impulsive and high- a trusting relationship, often with underestimate the likelihood that
risk behaviors (substance use), we the perpetrator misrepresenting their child might engage in online
did not find sexting to be a marker of himself as another child or teenager. conversation with people they do
mental health.”143 This developing online relationship not know. Therefore, it is critical
may lead to sexting or to convincing that parents promote online safety
Sexting is a behavior that will with their children from an early age,
likely continue and expand with the child to meet the perpetrator in
person. Children may be deceived, monitor children’s Internet use, and
technologic advances that make use tools, such as parental control
photography and communication tricked, or coerced into engaging
in sexual acts for the production software, to maintain awareness
more accessible. Active debate of their child’s online activities.151
continues regarding the ethical of child sexual abuse materials
(child pornography), which then Pediatricians should consider
and legal components of sexting, asking appropriate questions to
especially among underage youth. can circulate online for years to
come. Child sexual abuse images explore this possibility and to
Concerns include the identification educate youth about protecting
of sexts as pornography or sexual often involve young and very young
children. Of 43 597 children assessed themselves from exploitation. All
misconduct. Even consensual, health care professionals should
noncoercive sexting may result in in sexual abuse images and videos,
49.6% appeared to have a sexual report any suspicions of sexual
criminal prosecution that may lead to abuse/exploitation as per child abuse
long-term legal consequences. maturity rating of 1, and 28.7%
appeared to have a sexual maturity reporting laws.
Addressing risky sexual behaviors rating of 2.144 Besides the adverse
and psychological symptoms effects associated with child sexual
associated with sexting through abuse,145,146 victims who have had USE OF MEDIA BY PARENTS AND
education and guidance should online sexual images (pornography CAREGIVERS
help to promote wellness and and sexting) posted may experience
responsibility within adolescent significant anxiety and stress related What Effect Does Parent Media Use
populations. Further research to knowledge that the abuse images Have on Young and School-Aged
evaluating sexting among may be downloaded and viewed by Children and Teenagers?
gender minority populations (eg, millions of people for an indefinite Parents and caregivers play an
transgender adolescents) also period of time. Thus, the exploitation important role in modeling optimal
will be valuable in understanding continues for months and years after behaviors for their children in
and discouraging the behavior the images were obtained.144 general, including when it comes to

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the consumption and use of media. technology and childrearing, so and understand each family’s values
The growth of digital and social pediatric providers can support and health goals—for example, how
media, particularly in the last 5 their efforts to create boundaries good nutrition, an active lifestyle,
years, has seen dramatic increases in and “unplugged” zones in their good sleep hygiene, parent–child
adults’ use of social media as well as households. emotional connection, and creative
use by children and teenagers; more play fit into the family’s typical day—
than 70% of adults now use social and identify areas in which good
media152 and 27% report feeling THE FAMILY MEDIA USE PLAN health and wellness can be enhanced.
“addicted” to their mobile devices.7 Pediatricians can suggest ways in
Social media can provide positive • How can pediatric health care which media can be used to connect,
social experiences for adults, such as providers help families use media learn, and create instead of simply
opportunities for parents to connect in healthy ways? consume.
with their child in a college dorm • What is the AAP Family Media Use
via video-chatting services. Such These discussions can also allow
Plan? pediatric health care providers to
services also can promote social and
emotional connection among distant Pediatricians and other pediatric consider screening for problematic
relatives or deployed parents and health care professionals can be Internet use and Internet gaming
children. However, some parents can, helpful resources for families seeking disorder using validated tools, such
themselves, overuse digital media. specific advice about how to develop as the Internet Gaming Disorder
For example, research has shown that and individualize family rules and scale (https://www.researchgate.
parents’ own TV viewing distracts guidelines to meet their distinct net/publication/270652917_The_
from parent–child interactions153 and needs. Unfortunately, only 16% of Internet_Gaming_Disorder_Scale) and
children’s play.154 Children younger pediatricians ask families about the Problematic and Risky Internet
than 2 years are more likely to be their media use. In addition, only Use Screening Scale (http://mediad.
exposed to and watch inappropriate 29% of parents report relying on publicbroadcasting.net/p/kplu/
“background” media (eg, TV) than their pediatrician for advice about files/201502/PRIUSS_scale_and_
older children.155 Heavy parent broadcast and social media, although guidelines.pdf).
use of mobile devices is associated those who do tend to follow AAP
If challenges in implementing a
with fewer verbal and nonverbal recommendations.161
media use plan are anticipated,
interactions between parents and When discussing media use with pediatric health care providers can
children156 and may be associated families, pediatric health care consider introducing motivational
with more parent–child conflict.157 providers can print out and help interviewing or engaging in problem
families begin completing the AAP solving with parents and children
Because parent media use is a strong Family Media Use Plan (www. about possible solutions. The
predictor of child media habits,158 healthychildren.org/MediaUsePlan). pediatrician has an opportunity to
reducing parental TV viewing, Providers can discuss with parents discuss specific tools to address
including “background” TV, and and developmentally ready children identified family needs and concerns,
enhancing parent–child interactions how each of the media-specific including social services and
may be an important area of behavior behaviors and health concerns can be community resources, if needed.
change that pediatricians can help addressed through practical, family- Finally, the pediatrician may be able
to facilitate. Because parent–child centered approaches. The Family to provide families with referrals
interactions during family routines Media Use Plan can act as a teaching to educational and informational
are an important opportunity for tool through which pediatricians resources, such as vetted Web sites
emotional connection, have been can provide information about the (eg, www.HealthyChildren.org).
shown to be protective of child benefits and health risks of both
health outcomes, such as asthma and traditional and new media. The
high-risk behavior,159 and are the potential risks of interactive media,
primary driver of early childhood CONCLUSIONS
such as reduced physical activity,
development of language, cognition, inadequate sleep, and unhealthy New digital and social media
social skills, and emotion regulation, influences like cyberbullying and facilitate and promote social
it is important to preserve them. weight bias, are important to discuss interactions as well as participation
Parents often report feeling that with families as well. and engagement that involve both
technology speeds up their lives viewing and creating content. The
and work demands160 and that it The plan also can be a tool through effects of media use, however, are
is difficult to multitask between which the pediatrician can explore multifactorial and depend on the

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type of media, the type of use, the LIAISONS Balance. San Francisco, CA: Common
amount and extent of use, and the Kris Kaliebe, MD – American Academy of Child
Sense Media; 2016, Available at
characteristics of the individual and Adolescent Psychiatry https://www.commonsensemedia.
child or adolescent using the media. Jennifer Pomeranz, JD, MPH – American Public org/research/technology-addiction-
Health Association concern-controversy-and-finding-
Children today are growing up
Brian Wilcox, PhD – American Psychological balance. Accessed May 16, 2016
in an era of highly personalized
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parents should be encouraged to 2015 Sales, Demographic, and Usage
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Thomas McPheron Computer and Video Game Industry.
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AAP: American Academy of behavior: concurrent television and
can practice and benefit from the computer usage. Cyberpsychol Behav
Pediatrics
essentials for healthy growth and Soc Netw. 2011;14(9):527–534
app: application
development, such as a healthy
ASD: autism spectrum disorder 10. Moreno MA, Jelenchick L, Koff R,
diet, good sleep hygiene, adequate
LGBTQI: lesbian, gay, bisexual, Eickhoff JE, Diermyer C, Christakis DA.
physical activity, and positive social Internet use and multitasking among
transgender,
interactions. older adolescents: an experience
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144. Stanley J. Child abuse and the 153. Kirkorian HL, Pempek TA, Murphy work intensification, and employee
Internet. National Child Protection LA, Schmidt ME, Anderson DR. The strain and distress. Work Employ Soc.
Clearinghouse Series. 2001;15:1–18 impact of background television on 2014;28(4):589–610
parent-child interaction. Child Dev.
145. Kendall-Tackett KA, Williams LM, 161. Schmidt ME, Haines J, O’Brien A,
2009;80(5):1350–1359
Finkelhor D. Impact of sexual abuse et al. Systematic review of effective
on children: a review and synthesis of 154. Schmidt ME, Pempek TA, Kirkorian HL, strategies for reducing screen time
recent empirical studies. Psychol Bull. Lund AF, Anderson DR. The effects of among young children. Obesity (Silver
1993;113(1):164–180 background television on the toy play Spring). 2012;20(7):1338–1354

e18 FROM THE AMERICAN ACADEMY OF PEDIATRICS

 112
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

PowerPoint Presentation:
Toolkit Use in Primary Care
March 6, 2017

`
68 Click here for Algorithm
Click here for Table of Contents
 113

Reducing Screen Time for Children

Under Age 6 to Prevent
Language Delays
A Toolkit for Primary Care Providers
March 6, 2017
Cristina E. Kuta, DNPc, RN
University of Massachusetts Amherst, College of Nursing
Email: [email protected]
 114

Overview
—  Pre-Presentation Survey
—  DNP Capstone Project
—  Objectives
—  How Does Excessive Screen Time Affect
Language?
—  AAP Recommendations
—  Integrative Review of Evidence-Based Strategies
to Help Reduce Screen Time
—  Toolkit and Algorithm
—  Actions for Primary Care Providers
—  Conclusion and Post-Presentation Evaluation
 115

DNP Capstone Project

—  Personal Introduction
—  Doctor of Nursing Practice (DNP) degree
—  APRN scope of practice unchanged
—  Practice-focused doctorate
—  Requires final capstone project that translates
current research into clinical application
—  Capstone Project
—  Integrative Review
—  Toolkit
—  Presentation
 116

Objectives
1. Increase awareness about the potentially
harmful effects of excessive screen time on
language development in children younger
than 6 years old
2. Improve knowledge about evidence-based
strategies to reduce screen time for this age
group
3. Understand how to use family-centered
collaborative negotiation when discussing
lifestyle changes with patients and their
families
 117

How does excessive

screen time affect
language?
 118

How does excessive screen

time affect language?
—  Children 15-35 mos exposed to 137 min/day of
TV were 3.3 times more likely to develop a
language delay compared to those watching
<20 min/day

—  Hispanic infants & toddlers watching >2 hr/day

had 5.5 times higher risk of scoring lower in
communication on ASQ3 after 1 yr compared
to those watching <2 hr/day

Sources: Lin et al., 2015; Duch et al., 2013

 119

How does excessive screen

time affect language?
—  Children who started watching TV at <12 mos
old & watching >2 hr/day were 6 times more
likely to develop a language delay

—  In 2-3-yr-olds, for every 1 hr of TV watched, they

were exposed to 500-1000 fewer words with
significant reductions in their vocalizations,
vocalization duration, & conversational turns
with more TV time

Sources: Chonchaiya & Pruksananonda, 2008; Christakis et al., 2009

 120

How does excessive screen

time affect language?
—  Parents spoke in shorter, 1-word sentences &
spoke less words overall to their children when
the TV was on

—  Children who watched TV alone were 8.5 times

more likely to develop a language delay

Sources: Tanimura et al., 2007; Chonchaiya & Pruksananonda, 2008

 How much screen time are
121

children exposed to?

—  90% of children <2
yrs are exposed to 1-2
hr/day of TV with 14%
watching >2 hr/day
—  38% of infants use
mobile devices like
smartphones
—  Typical American child
<5 yrs watches 4.5 hr/
day of TV
Sources: AAP, 2011; Christakis, 2011; Rideout, 2013
 122

Why is this important?

Receptive language delays by age 5 are a
significant risk factor for social and emotional
problems in adulthood

Source: Schoon et al., 2010

 123

Additional Health Risks

—  Obesity —  Migraine headaches
—  Violence —  Repetitive motion
—  Aggression syndrome &
—  Loss of social skills arthritis

—  Attention problems
—  Anxiety &
depression
—  Sleep deprivation
—  Vision problems
 124

American Academy
of Pediatrics
Recommendations
 125

AAP Recommendations
—  No screen time for children <18-24 months,
except video-chatting
—  Limit screen time <1 hr/day of high-quality
programming/apps for children ages 2-5
—  Caregivers should co-view & co-use media
—  No screen time during meals or for 1 hr
before bedtime
—  Remove TVs & other media devices
from children’s bedrooms
Source: AAP, 2016
 126

Primary Care Opportunities

—  Primary care setting ideal for screen time
education because patients seen 12 times
for routine wellness visits from ages 2-
months to 5-years

—  However, only 16% of pediatricians in the

U.S. ask about media use
Sources: AAP, 2016; Shifrin et al., 2015
 127

Integrative Review of
Evidence-Based
Strategies to Reduce
Screen Time
 128

Evidence-Based Strategies
to Help Reduce Screen Time
Integrative review of 10 studies:
— 2 systematic review/meta-analyses
— 5 RCTs
— 2 pilot RCTs
— 1 pilot non-RCT
Resulted in significant reductions in
screen time by 34 min/day on average
Sources: Birken et al., 2012; Campbell et al., 2013; Dennison et al., 2004; Downing et al., 2016;
Hinkley et al., 2015; Taveras et al., 2011a; Taveras et al., 2011b; Wahi et al., 2011; Yilmaz et al., 2014;
Zimmerman et al., 2012
 129

Evidence-Based Strategies
to Help Reduce Screen Time
Interventions included:
— Recurrent education using family-centered
collaborative negotiation & printed materials
over multiple visits
— Setting rules for use
— Co-viewing & co-using media
— Displacing screen time with other activities
— Removing TVs & other media devices from
children’s bedrooms
 130

Toolkit and Algorithm

 Toolkit
131

Content Summary
—  Introduction and Purpose
—  Evidence-Based Strategies to Reduce
Screen Time
—  Actions for Primary Care Providers
—  2016 AAP Policy Statement and
Technical Report
—  Motivational Interviewing Resources
—  Family-Centered Collaborative
Negotiation Article
—  Local Child Development Community
Resources
—  Patient Education Resources
(Brochure, Poster, Family Media Use
Plan, Websites)
 Screen Time Reduction Algorithm 132

Age-appropriate history,
relevant screening tools Perform 2-Question
(i.e. ASQ-3, MCHAT-R), Conduct screen Tools to guide
Assessment for time educational discussion
and physical exam Screen Time discussion with
(2-QAST) caregivers
-click here- Click here for
Brochure
Click here for
Risk for or existing Motivational
language Interviewing (MI) Click here for
developmental delay Training Resources Poster

Click here for

Specifically, use Family-
Family Media
Centered Collaborative
Click here for Use Plan
Negotiation (type of MI).
Child Development -click here for article-
Community
Resources
No screen time, <18-24 Co-use & co-view
except video months media
chat old
Encourage Set rules: No
alternative screen time
<1 hr/day HIGH 2-5
activities and during family
quality screen years
daily reading meals and 1-hr
time old
before bed

Legend:
direct route No TVs or media
Click here for
indirect route devices in
Websites for
bedroom
Families © 2017 Cristina Kuta
 133

Actions for
Primary Care Providers
 Actions for
134

Primary Care Providers

Use the 2-Question Assessment for Screen
Time (2-QAST) at every wellness visit:
1. How much screen time (min/hr) does your
child consume daily?
2. Is there a TV or mobile media device
(tablet/iPad, cell phone, computer) in your
child’s bedroom?

Source: AAP, 2013

 Actions for
135

Primary Care Providers

Providers should briefly cover the following:
ü Excessive screen time leads to increased risk
of language delays in children <6 yrs old
ü Discourage screen time for children <18-24
mos old, except video-chat
ü Encourage a 1-hr daily limit of high-quality
screen time for 2-5 yr olds. Direct families to
Common Sense Media to find age-appropriate
high-quality media.
 136

Actions for
Primary Care Providers
ü Encourage creation of a Family Media Use Plan
ü Encourage caregivers to co-view & co-use media
ü Encourage caregivers to read to their children
for at least 20 min/day using an interactive
approach
ü Encourage caregivers to not allow screens
during family meal times & 1 hr before bedtime
ü Encourage caregivers to remove TVs and other
media devices from their child’s bedroom
 Actions for
137

Primary Care Providers

Patient Education Resources:
—  Brochure
—  Poster
—  Family Media Use Plan
—  Websites
 Family-Centered
Collaborative Negotiation
—  Brief 5 to 15 min —  Provide no
—  Empathetic unsolicited advice
—  Collaborative — Ask permission
—  Patient-centered — Use open-ended
—  Self-motivational questions
statement — Listen reflectively
—  Support self-efficacy —  Roll with resistance
—  Family/patient decide
course of action

Source: Tyler & Horner, 2008

 139

Conclusion
—  Questions?
—  Post-presentation evaluation
—  Thank you for participating!
 140

Thank You
—  Chairperson: Dr. Jean DeMartinis, PhD, FNP-BC
—  Clinical Preceptors:
—  Lt Col Brian Glodt, MD
—  Lt Col Frederico Aguilar, MD
—  Maj Jonathan Davis, MD
—  Capt Aubrey Berber, PNP
—  Capt Kristina Zucarelli, FNP
—  Capt Joel Harris, PA
—  Capt Taryn Thompson, PA
—  Lt Andrea Sumner, PA
—  Thank you to my husband, Maj Matthew Kuta,
for supporting me in my academic journey
 141
References
American Academy of Pediatrics. (2011). Media use by children younger than 2 years. Pediatrics, 128(5), 1040-1045.

American Academy of Pediatrics. (2016). Policy statement: Media and young minds. Pediatrics, 138(5), 1-6.

Beck, A. L., Takayama, J., Badiner, N., & Halpern-Felsher, B. (2015). Latino parents beliefs about television-viewing by infants and
toddlers. Journal of Health Care for the Poor and Underserved, 26, 463-474.

Birken, C. S., Maguire, J., Mekky, M., Manlhiot, C., Beck, C. E., DeGroot, J., . . . Parkin, P. (2012). Office-based randomized
controlled trial to reduce screen time in preschool children. Pediatrics, 130(6), 1110-1115.

Campbell, K. J., Lioret, S., McNaughton, S. A., Crawford, D. A., Salmon, J., Ball, K., . . . Hesketh, K. D. (2013). A parent-focused
intervention to reduce infant obesity risk behaviors: A randomized trial. Pediatrics, 131(4), 652-660.

Chonchaiya, W., & Pruksananonda, C. (2008). Television viewing associates with delayed language development. Acta Paediatrica,
97, 977-982.
Christakis, D. A. (2011, December 28). TEDxRainier Dimitri Christakis: Media and children. [Video file]. Retrieved from https://
youtu.be/BoT7qH_uVNo

Christakis, D. A., Gilkerson, J., Richards, J. A., Zimmerman, F. J., Garrison, M. M., Xu, D., . . . Yapanel, U. (2009). Audible television
and decreased adult words, infant vocalizations, and conversational turns: A population-based study. Archives of Pediatrics and
Adolescent Medicine, 163(6), 554-558.

Dennison, B. A., Russo, T. J., Burdick, P. A., & Jenkins, P. L. (2004). An intervention to reduce television viewing by preschool
children. Archives of Pediatrics and Adolescent Medicine, 158(2), 170-176.

Downing, K. L., Hnatiuk, J. A., Hinkley, T., Salmon, J., & Hesketh, K. D. (2016). Interventions to reduce sedentary behaviour in 0-5-
year-olds: A systematic review and meta-analysis of randomised controlled trials. British Jounral of Sports Medicine, 0, 1-9.

Duch, H., Fisher, E. M., Ensari, I., Font, M., Harrington, A., Taromino, C., . . . Rodriguez, C. (2013). Association of screen time use
and language development in hispanic toddlers: A cross-sectional and longitudinal study. Clinical Pediatrics, 52(9), 857-865.

Hinkley, T., Cliff, D. P., & Okely, A. D. (2015). Reducing electronic media use in 2-3 year-old children: Feasibility and efficacy of the
Family@play pilot randomised controlled trial. BMC Health, 15(779), 1-12.

Lin, L. Y., Cherng, R. J, Chen, Y. J., Chen, Y. J., & Yang, H. M. (2015). Effects of television exposure on developmental skills among
young children. Infant Behavior and Development, 38, 20-26.
Kuhl, P. K. (2004). Early language acquisition: Cracking the speech code. Nature Reviews, 5, 831-843.

Rideout, V. (2013). Zero to eight: children’s media use in America 2013: A Common Sense research study. Common Sense Media.
Retrieved from www.commonsensemedia.org
 142
References
Schoon, I., Parsons, S., Rush, R., & Law, J. (2010). Children’s language ability and psycholosocial development: A 29-year follow-
up study. Pediatrics, 126(1), e73-e80.

Shifrin, D., Brown, A., Hill, D., Jana, L., & Flinn, S. K. (2015, October 1). Growing up digital: Media research symposium. American
Academy of Pediatrics.

Stolten, K., Abrahamsson, N., & Hyltenstam, K. (2014). Effects of age of learning on voice onset time: Categorical perception of
swedish stops by near-native L2 speakers. Language and Speech, 57(4), 425-450.

Tanimura, M., Okuma, K., & Kyoshima, K. (2007). Television viewing, reduced parental utterance, and delayed speech
development in infants and young children. Archives of Pediatric and Adolescent Medicine, 161, 618-619.

Taveras, E. M., Gillman, M. W., & McDonald, J. (2011). First ste ps for mommy and me: A pilot intervention to imrpove nutrition
and physical activity behaviors of postpartum mothers and their infants. Maternal Child Health, 15, 1217-1227.

Taveras, E. M., Gortmaker, S. L., Hohman, K. H., Horan, C. M., Kleinman, K. P., Mitchell, K., . . . Gillman, M. W. (2011).
Randomized controlled trial to improve primary care to prevent and manage childhood obesity. Archives of Pediatric Adolescent
Medicine, 165(8), 714-722.

Tyler, D. O. & Horner, S. (2008). Family-centered collaborative negotiation: A model for facilitating behavior change in primary
care. Journal of the American Academy of Nurse Practitioners, 20, 194-203.

Van Grieken, A., Renders, C. M., Veldhuis, L., Looman, C. W., Hirasing, R. A., & Raat, H. (2014). Promotion of a healthy lifestyle
among 5-year-old overweight children: Health behavior outcomes of the ‘Be active, eat right’ study. BMC Public Health, 14(59),
1-24.

Vandewater, E. A., Bickham, D. S., Lee, J. H., Cummings, H. M., Wartella, E. A., & Rideout, V. J. (2005). When the television is
always on: heavy television exposure and young children’s development. American Behavioral Scientist, 48(5), 562-577.

Wahi, G., Parkin, P. C., Beyene, J., Uleryk, E. M., & Birkne, C. (2011). Effectiveness of interventions aimed at reducing screen time
in children: A systematic review and meta-analysis of randomized controlled trials. Archives of Pediatrics and Adolescent Medicine,
165(11), 979-986.

Yilmaz, G., Caylan, N. D., & Karacan, C. D. (2014). An intervention to preschool children for reducing screen time: A randomized
controlled trial. Child: Care, Health and Development, 41(3), 443-449.

Zimmerman, F. J., Ortiz, S. E., Christakis, D. A., & Elkun, D. (2012). The value of social-cognitive theory to reducing preschool TV
viewing: A pilot randomized trial. Preventive Medicine, 54, 212-218.
 143

References

American Academy of Pediatrics. (2011). Media use by children younger than 2

years. Pediatrics, 128(5), 1040-1045.
American Academy of Pediatrics. (2016). Policy statement: Media and young
minds. Pediatrics, 138(5), 1-6.
Beck, A. L., Takayama, J., Badiner, N., & Halpern-Felsher, B. (2015). Latino parents
beliefs about television-viewing by infants and toddlers. Journal of Health
Care for the Poor and Underserved, 26, 463-474.
Birken, C. S., Maguire, J., Mekky, M., Manlhiot, C., Beck, C. E., DeGroot, J., . . .
Parkin, P. (2012). Office-based randomized controlled trial to reduce
screen time in preschool children. Pediatrics, 130(6), 1110-1115.
Campbell, K. J., Lioret, S., McNaughton, S. A., Crawford, D. A., Salmon, J., Ball, K.,
. . . Hesketh, K. D. (2013). A parent-focused intervention to reduce infant
obesity risk behaviors: A randomized trial. Pediatrics, 131(4), 652-660.
Chonchaiya, W., & Pruksananonda, C. (2008). Television viewing associates with
delayed language development. Acta Paediatrica, 97, 977-982.
Christakis, D. A. (2011, December 28). TEDxRainier Dimitri Christakis: Media and
children. [Video file]. Retrieved from https://youtu.be/BoT7qH_uVNo
Christakis, D. A., Gilkerson, J., Richards, J. A., Zimmerman, F. J., Garrison, M. M.,
Xu, D., . . . Yapanel, U. (2009). Audible television and decreased adult
words, infant vocalizations, and conversational turns: A population-based
study. Archives of Pediatrics and Adolescent Medicine, 163(6), 554-558.
Dennison, B. A., Russo, T. J., Burdick, P. A., & Jenkins, P. L. (2004). An intervention
to reduce television viewing by preschool children. Archives of Pediatrics
and Adolescent Medicine, 158(2), 170-176.
Downing, K. L., Hnatiuk, J. A., Hinkley, T., Salmon, J., & Hesketh, K. D. (2016).
Interventions to reduce sedentary behaviour in 0-5-year-olds: A systematic

99 Click here for Algorithm

Click here for Table of Contents
 144

review and meta-analysis of randomised controlled trials. British Jounral of

Sports Medicine, 0, 1-9.
Duch, H., Fisher, E. M., Ensari, I., Font, M., Harrington, A., Taromino, C., . . .
Rodriguez, C. (2013). Association of screen time use and language
development in hispanic toddlers: A cross-sectional and longitudinal
study. Clinical Pediatrics, 52(9), 857-865.
Hinkley, T., Cliff, D. P., & Okely, A. D. (2015). Reducing electronic media use in 2-3
year-old children: Feasibility and efficacy of the Family@play pilot
randomised controlled trial. BMC Health, 15(779), 1-12.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Lin, L. Y., Cherng, R. J, Chen, Y. J., Chen, Y. J., & Yang, H. M. (2015). Effects of
television exposure on developmental skills among young children. Infant
Behavior and Development, 38, 20-26.
Kuhl, P. K. (2004). Early language acquisition: Cracking the speech code. Nature
Reviews, 5, 831-843.
Rideout, V. (2013). Zero to eight: children’s media use in America 2013: A
Common Sense research study. Common Sense Media. Retrieved from
www.commonsensemedia.org

Schoon, I., Parsons, S., Rush, R., & Law, J. (2010). Children’s language ability and
psycholosocial development: A 29-year follow-up study. Pediatrics, 126(1),
e73-e80.

Shifrin, D., Brown, A., Hill, D., Jana, L., & Flinn, S. K. (2015, October 1). Growing up
digital: Media research symposium. American Academy of Pediatrics.

Stolten, K., Abrahamsson, N., & Hyltenstam, K. (2014). Effects of age of learning
on voice onset time: Categorical perception of swedish stops by near-
native L2 speakers. Language and Speech, 57(4), 425-450.
Tanimura, M., Okuma, K., & Kyoshima, K. (2007). Television viewing, reduced
parental utterance, and delayed speech development in infants and

`
100 Click here for Algorithm
Click here for Table of Contents
 145
young children. Archives of Pediatric and Adolescent Medicine, 161, 618-
619.
Taveras, E. M., Gillman, M. W., & McDonald, J. (2011). First ste ps for mommy and
me: A pilot intervention to imrpove nutrition and physical activity
behaviors of postpartum mothers and their infants. Maternal Child Health,
15, 1217-1227.
Taveras, E. M., Gortmaker, S. L., Hohman, K. H., Horan, C. M., Kleinman, K. P.,
Mitchell, K., . . . Gillman, M. W. (2011). Randomized controlled trial to
improve primary care to prevent and manage childhood obesity.
Reducing Screen Time for Children Under Age 6 to Prevent Language Delays | March 2017

Archives of Pediatric Adolescent Medicine, 165(8), 714-722.

Tyler, D. O. & Horner, S. (2008). Family-centered collaborative negotiation: A
model for facilitating behavior change in primary care. Journal of the
American Academy of Nurse Practitioners, 20, 194-203.
Vandewater, E. A., Bickham, D. S., Lee, J. H., Cummings, H. M., Wartella, E. A., &
Rideout, V. J. (2005). When the television is always on: heavy television
exposure and young children’s development. American Behavioral
Scientist, 48(5), 562-577.
Wahi, G., Parkin, P. C., Beyene, J., Uleryk, E. M., & Birkne, C. (2011). Effectiveness
of interventions aimed at reducing screen time in children: A systematic
review and meta-analysis of randomized controlled trials. Archives of
Pediatrics and Adolescent Medicine, 165(11), 979-986.

Yilmaz, G., Caylan, N. D., & Karacan, C. D. (2014). An intervention to preschool

children for reducing screen time: A randomized controlled trial. Child:
Care, Health and Development, 41(3), 443-449.

Zimmerman, F. J., Ortiz, S. E., Christakis, D. A., & Elkun, D. (2012). The value of
social-cognitive theory to reducing preschool TV viewing: A pilot
randomized trial. Preventive Medicine, 54, 212-218.

101 Click here for Algorithm

Click here for Table of Contents
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 146

Appendix C

Pre-Presentation Survey
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 147
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 148

Appendix D

Post-Presentation Evaluation
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 149
Running head: IMPACT OF SCREEN TIME ON LANGUAGE DEVELOPMENT 150

Appendix E

Internal Review Board Letter of Exemption